Interpersonal relationships in patients suffering from chronic musculoskeletal pain: a case-control study analyzing core conflictual relationship themes and interpersonal problems

BackgroundThe alleviation of pain is a key aim of health care yet pain can often remain a puzzle as it is not always explained by a specific pathology. Musculoskeletal (MSK) pain is one of the most predominant kinds of chronic pain and its prevalence is increasing. One of the aims of qualitative research in health care is to understand the experience of illness, and make sense of the complex processes involved. However, the proliferation of qualitative studies can make it difficult to use this knowledge. There has been no attempt to systematically review and integrate the findings of qualitative research in order to increase our understanding of chronic MSK pain. A synthesis of qualitative research would help us to understand what it is like to have chronic MSK pain. Specifically, it would help us understand peoples' experience of health care with the aim of improving it.AimThe aim of this study was to increase our understanding of patients’ experience of chronic non-malignant MSK pain; utilise existing research knowledge to improve understanding and, thus, best practice in patient care; and contribute to the development of methods for qualitative research synthesis.MethodsWe used the methods of meta-ethnography, which aim to develop concepts that help us to understand a particular experience, by synthesising research findings. We searched six electronic bibliographic databases (including MEDLINE, EMBASE and PsycINFO) and included studies up until the final search in February 2012. We also hand-searched particular journals known to report qualitative studies and searched reference lists of all relevant qualitative studies for further potential studies. We appraised each study to decide whether or not to include it. The full texts of 321 potentially relevant studies were screened, of which 77 qualitative studies that explored adults’ experience of chronic non-malignant MSK pain were included. Twenty-eight of these studies explored the experience of fibromyalgia.ResultsOur findings revealed the new concept of an adversarial struggle that explains the experience of people with chronic MSK pain. This included the struggle to affirm self and construct self over time; find an explanation for pain; negotiate the health-care system while feeling compelled to stay in it; be valued and believed; and find the right balance between sick/well and hiding/showing pain. In spite of this struggle, our model showed that some people were able to move forward alongside their pain by listening to their body rather than fighting it; letting go of the old self and finding a new self; becoming part of a community and not feeling like the only one; telling others about pain and redefining relationships; realising that pain is here to stay rather than focusing on diagnosis and cure; and becoming the expert and making choices. We offer unique methodological innovations for meta-ethnography, which allowed us to develop a conceptual model that is grounded in 77 original studies. In particular, we describe a collaborative approach to interpreting the primary studies.ConclusionOur model helps us to understand the experience of people with chronic MSK pain as a constant adversarial struggle. This may distinguish it from other types of pain. This study opens up possibilities for therapies that aim to help a person to move forward alongside pain. Our findings call on us to challenge some of the cultural notions about illness, in particular the expectation of achieving a diagnosis and cure. Cultural expectations are deep-rooted and can deeply affect the experience of pain. We therefore should incorporate cultural categories into our understanding of pain. Not feeling believed can have an impact on a person’s participation in everyday life. The qualitative studies in this meta-ethnography revealed that people with chronic MSK pain still do not feel believed. This has clear implications for clinical practice. Our model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed by pain. Listening to a person’s narratives can help us to understand the impact of pain. Our model suggests that feeling valued is not simply an adjunct to the therapy, but central to it. Further conceptual syntheses would help us make qualitative research accessible to a wider relevant audience. Further primary qualitative research focusing on reconciling acceptance with moving forward with pain might help us to further understand the experience of pain. Our study highlights the need for research to explore educational strategies aimed at improving patients’ and clinicians’ experience of care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Background:Paediatric chronic lower limb pain is common, and often distressing and disabling for children and adolescents. Recently, the classification of chronic pain conditions changed within the International Classification of Diseases...

Purpose: To compare physical activity levels of adolescents and young adults with chronic pain with that of healthy participants. To investigate the impact of pain intensity, pain catastrophizing and depressive symptoms on the level of physical activity and disability of adolescents and young adults with chronic pain. Methods: Case-control study. Levels of physical activity and disability of adolescents and young adults with chronic non-specific musculoskeletal pain (n = 42) were compared with that of healthy participants (n = 42). For participants with chronic pain, measures of pain catastrophizing, pain intensity and depression were examined for their ability to explain levels of physical activity and disability. Statistics: multivariate regression analysis, Mann-Whitney testing, Pearson correlation analysis. Results: Participants with chronic pain were as active as healthy participants (p = 0.22) (confidence interval [CI] 95%), although they seemed to be less active in sports and heavy-loaded activities. Pain intensity (ß = 0.32) and depressive symptoms (ß = 0.36) contributed significantly to disability (CI 95%). There was no significant association between physical activity and disability (CI 95%). Conclusions: Chronic non-specific musculoskeletal pain is a disabling condition for adolescents and young adults. The level of physical activity in the daily life of adolescents and young adults with chronic pain is comparable to that of healthy counterparts, although the performance of sports and heavy-loaded activities seems diminished. Both pain intensity and depressive symptoms are disabling.Implications for RehabilitationChronic non-specific musculoskeletal pain is a disabling condition for adolescents and young adults.Pain intensity and depressive symptoms predict disability.The effect of pain on the physical-activity level of adolescents and young adults with chronic non-specific musculoskeletal pain seems to be small.Assessment and improvement of emotional well-being may improve treatment programs for adolescents and young adults with chronic non-specific musculoskeletal pain.

Chronic non-specific musculoskeletal pain is a common problem among adolescents. This study investigates the importance of future goals and goal frustration for adolescents and young adults with chronic musculoskeletal pain compared to healthy adolescents. It also explores the impact that pain intensity, pain catastrophizing and depressive symptoms have on goal frustration for adolescents with chronic pain. Using a cross-sectional design, we compared the importance and frustration of future goals for 42 adolescents and young adults with chronic musculoskeletal pain (41 women, 1 man) to those of 42 adolescents without pain (35 women, 7 men). For the adolescents with chronic pain, we also examined levels of pain intensity, pain catastrophizing and depressive symptoms to assess their ability to explain goal frustration levels. Statistics included t-tests, Mann-Whitney test and multivariate regression analysis. We found no differences in the importance of future goals, except for goals related to health, which were more important for adolescents with chronic pain (p=0.03). Furthermore, adolescents with chronic pain perceived higher levels of goal frustration in all domains, except that related to school (p=0.16). Depression explained goal frustration related to personal values (p=0.02), social acceptance (p<0.01), self-acceptance (p<0.01) and health (p<0.01). Dealing with chronic pain in adolescence and early adulthood does not seem to change future goals, but is associated with perceiving barriers to achieving them. The level of depressive symptoms seems to influence this relationship. Some caution is required in generalizing the results due to the relatively low number of male participants.

Chronic musculoskeletal pain is defined as chronic pain arising from musculoskeletal structures such as bones or joints. Although comprising the most prevalent set of chronic pain conditions, it was not represented appropriately in the 10th edition of the International Classification of Diseases (ICD-10), which was organized mainly according to anatomical sites, was strongly focused on musculoskeletal disease or local damage, and did not consider the underlying mechanisms of pain. The new ICD-11 classification introduces the concept of chronic primary and secondary musculoskeletal pain, and integrates the biomedical axis with the psychological and social axes that comprise the complex experience of chronic musculoskeletal pain. Chronic primary musculoskeletal pain is a condition in its own right, not better accounted for by a specific classified disease. Chronic secondary musculoskeletal pain is a symptom that arises from an underlying disease classified elsewhere. Such secondary musculoskeletal pain originates in persistent nociception in musculoskeletal structures from local or systemic etiologies, or it may be related to deep somatic lesions. It can be caused by inflammation, by structural changes, or by biomechanical consequences of diseases of the nervous system. It is intended that this new classification will facilitate access to patient-centered multimodal pain management and promote research through more accurate epidemiological analyses.

Serum Vitamin D and Chronic Musculoskeletal Pain: A Cross-Sectional Study of 349,221 Adults in the UK

Purpose: To identify determinants for staying at work (SAW) in workers with chronic musculoskeletal pain (CMP). Method: A systematic review of factors that promote SAW in workers with CMP. We searched the databases of PubMed, EMBASE, PsycInfo, CINAHL and the Cochrane Library. We included studies reporting on working subjects without present CMP-related sick leave. A quality assessment of GRADE criteria and evidence synthesis was performed. Results: We identified five cross-sectional studies and two qualitative studies reporting on factors associated with SAW in workers with CMP. Consistent association with SAW was found for low perceived physical disability and low emotional distress (low-level evidence). Duration of pain, catastrophizing, self-esteem and marital status were not associated with SAW (low-level evidence). Qualitative studies indicated that personal adjustments and workplace interventions are important determinants for SAW (evidence not graded). Conclusions: No high-level evidence for SAW determinants for workers with CMP was identified. Future interventions aimed at promoting SAW could consider reducing perceived physical disability and emotional distress, and promoting adjustment latitude at work, support from supervisors, and the workers’ motivation and self-management skills. Further research is required because knowledge of SAW in workers with CMP is scarce, and the relevance of the subject is high.Implications for RehabilitationWhen modifiable factors that promote staying at work can be identified, interventions can be developed to support the ability of workers with chronic nonspecific musculoskeletal pain to stay at work.Consistent evidence of promoting staying at work was found for low emotional distress and perceived physical disability, while duration of pain, catastrophizing, self-esteem and marital status were consistently not associated.Future interventions aimed at promoting staying at work should consider reducing perceived physical disability and emotional distress.

BackgroundResearch suggests that the onset of musculoskeletal pain and its evolution into a chronic condition is related to adverse psychosocial contexts throughout the life course. However, the specific individual socioeconomic...

A meta-ethnography of patients' experience of chronic non-malignant musculoskeletal pain

Evidence of physical deconditioning in adolescents with juvenile fibromyalgia: deficiencies in strength and balance

Background In recent years, a growing number of researchers showed significant interest in psychological and social interventions to manage chronic musculoskeletal (MSK) pain. Cognitive and emotional empathy is an attractive and valuable sociopsychological factor that may provide protection and resilience against chronic MSK pain. However, its effect on outpatients remains underexplored. Objective To compare the empathy ability between chronic MSK pain outpatients and healthy controls and explore the relationship between cognitive/emotional empathy and chronic pain. Methods Patients with chronic MSK pain (n = 22) and healthy controls (n = 26) completed the pain assessment and empathy ability task, utilizing a multidimensional empathy assessment tool with satisfactory reliability and validity (i.e., the Chinese version of the Multifaceted Empathy Test (MET-C)). Results The data indicated that the chronic MSK pain outpatients had impaired cognitive empathy (i.e., lower squared cognitive empathy accuracy: Student's t = −2.119, P = 0.040, and longer task completion time: Student's t = 3.382, P = 0.002) compared to healthy controls, and cognitive empathy was negatively correlated with pain intensity (r = −0.614, P = 0.002). Further, the impaired cognitive empathy was present in identifying positive, but not negative emotions. Conclusion These results indicate that chronic MSK pain is associated with impaired empathy ability. Our studies contribute to offering a potential direction for developing psychosocial interventions to treat chronic MSK pain.

To investigate the frequency and health impact of chronic multi-site musculoskeletal pain, in a representative UK sample. Population postal questionnaire survey, using 16 general practices in the southeast of England, nationally representative urban/rural, ethnic and socioeconomic mix. A random selection of 4049 registered patients, aged 18 or over, were sent a questionnaire. The main outcome measures were chronic pain location, identified using a pain drawing; distress, pain intensity and disability as measured by the GHQ12 and the Chronic Pain Grade. A total of 2445 patients (60%) responded to the survey (44% male, mean age 52 yrs); 45% had chronic musculoskeletal pain. Of those with chronic pain, three quarters had pain in multiple sites (two or more sites). Variables significantly predicting this were: age under 55, [odds ratio (OR) 0.5, 95% confidence interval (CI) 0.4, 0.6]; psychological distress (OR 1.8, CI at 95% 1.4, 2.2) and high pain intensity (OR 5.2, CI at 95% 4.1, 6.7). Only 33% of multi-site pain distributions conformed to the American College of Rheumatology definition of chronic widespread pain. Multi-site chronic pain is more common than single-site chronic pain and is commonly associated with other problems. Indiscriminate targeting of research and care for chronic musculoskeletal pain on single sites may often be inappropriate.

BACKGROUND AND OBJECTIVES: Joint mobilization is a non-pharmacological technique used to treat chronic musculoskeletal pain. However, it is controversial due to a lack of studies comparing its effects on this painful condition. The objective of this study was to assess the risk of bias in clinical trials investigating the effect of joint mobilization on chronic musculoskeletal pain. CONTENTS: A systematic search on Pubmed, Cochrane Library, ScienceDirect, Scielo, PEDro, CINAHL, SPORTDiscus, LILACS, BVS, PsycINFO, Web of Science, and Scopus was performed on September 2019 from the combination of three keywords: Musculoskeletal Manipulations AND Chronic Pain AND Musculoskeletal Pain. Randomized controlled clinical trials that evaluated the use of joint mobilization associated or not to other therapies in chronic musculoskeletal pain treatment were included. Five thousand five hundred eighty-seven articles were screened, and 14 studies were analyzed, including 812 participants, with a mean age of 54 years, and female being the most affected. According to these articles, joint mobilization promoted the reduction of pain intensity in short and long terms, increase in range of motion, strength and function when used alone or in association with conventional physiotherapy. Regarding methodological quality, most of the studies were classified with low risk for selection, performance, detection and reporting bias. In the “other bias” item, which considered therapists experience time and types of treatment applied, only one study presented low risk and other study presented an unclear risk. CONCLUSION: Joint mobilization seems to be an effective technique for the treatment of chronic musculoskeletal pain. However, it is still necessary to investigate and compile studies with greater methodological quality, thus promoting greater support to evidence-based practice.

BackgroundThe purpose of this cross-sectional study was to test the hypothesis that serum vitamin D levels are abnormally low in sleep clinic patients admitting to chronic nonspecific musculoskeletal pain and to assess the associated risk factors. A secondary purpose was to identify a clinical biomarker for vitamin D deficiency.MethodsWe enrolled 153 consecutive patients who admitted to the presence of chronic nonspecific musculoskeletal pain during a comprehensive sleep evaluation at a specialist sleep medicine clinic within an academic center. Venous blood sampling was performed for determination of serum 25-hydroxyvitamin D. Risk factors for vitamin D deficiency (25-hydroxyvitamin D < 20 ng/mL) were identified by odds ratios. Receiver-operating characteristic curve analysis was performed with 10-fold cross-validation to identify a biomarker for vitamin D deficiency calculated by linear discriminant analysis.ResultsThe mean serum 25-hydroxyvitamin D level was 19.8 ± 11.1, with 54% of the study population having vitamin D deficiency. This mean 25-hydroxyvitamin D level was lower than that observed historically in healthy controls, and was either similar or lower than in all but one representative historical cohort formed on the basis of chronic nonspecific musculoskeletal pain. Risk factors for vitamin D deficiency were black ethnicity, age < 60 years, and obesity. These risk factors were identified both in the entire cohort and separately in subgroups with and without obstructive sleep apnea. The biomarker (based on race, age, and body mass index) had a sensitivity and specificity for predicting vitamin D deficiency of 0.73 and 0.74, respectively.ConclusionVitamin D deficiency was prevalent in patients with sleep disorders and chronic nonspecific musculoskeletal pain on evaluation in a sleep medicine clinic. Vitamin D deficiency was reliably estimated in the study population using a biomarker derived from common demographic characteristics.

To identify the types of conditions reported in peer-reviewed literature that result in chronic musculoskeletal lower limb pain in children and adolescents and explore the alignment of these conditions with the chronic pain reporting codes indexed in the International Classification of Diseases 11th Revision (ICD-11). This scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five electronic databases were searched (Medline, EMBASE, PsycINFO, CINAHL and the Cochrane Library). Articles involving children and adolescents under 18 years and reporting on chronic musculoskeletal pain of the lower limb were included. We assigned an ICD-11 code to each condition based on details reported in the study. We recorded whether any of the presenting conditions were linked to an ICD-11 chronic pain manifestation code. From 12 343 records, 418 papers were included. There were 124 unique conditions associated with chronic lower limb pain, the most commonly reported being chronic widespread musculoskeletal pain (24 studies) and juvenile idiopathic arthritis (26 studies). Only 11.1% of presenting conditions were linked to an ICD-11 chronic pain manifestation code. Most presenting conditions associated with chronic pain in the lower limb do not have a chronic pain manifestation code in the new global standard for recording health information. This means chronic pain associated with common lower limb conditions may remain invisible in global statistics.