Non-inflammatory Musculoskeletal Pain Research Articles

Recruiting patients and collecting data for an observational study using computerised record pop-up prompts: the PROG-RES study.

Engagement of general practitioners (GPs) and recruitment of patients are ever present problems in primary care studies. This paper seeks to demonstrate that electronic prompts represent one method of easing the burden on GPs to recruit individual patients to studies and also provide the opportunity to collect research data during a normal consultation. Older adults consulting for non-inflammatory musculoskeletal pain from five general practices in Cheshire were recruited to a prospective cohort study (the PROG-RES study). Recruitment of patients was aided by a computer prompt during relevant consultations. When triggered by an appropriate Read code, a pop-up template appeared on the consultation screen prompting the GPs to record the answers to seven brief questions. A self-complete questionnaire was mailed to patients who had completed templates by the Keele GP Research Network team and permission was sought to access their medical records. A feasibility study suggested that the potential number of activated templates in the practice within four months would be 636. The 44 GPs completed 650 electronic templates during the four-month recruitment period. Almost 40% of recruitment was within four weeks and greater than 95% of recruitment was within 16 weeks. Practices A-D completed electronic templates at a similar rate (1.61-1.86 templates per 1000 patients), although practice E completed templates at a lower frequency (0.76) due to internal difficulties. Completion of individual items ranged from 98% to 83% and completion of all seven questions was recorded in 63% of patients; 4% of patients had three or fewer responses recorded. Conclusion Templates activated by appropriate codes in the GP consultation can facilitate recruitment to observational studies in primary care. It is possible to collect high-quality research data within a normal consultation. This may be a model for use in future studies in primary care.

The association between pain intensity and the prescription of analgesics and non-steroidal anti-inflammatory drugs.

BackgroundIt is not known whether general practitioners (GPs) prescribe analgesic medication according to intensity of pain or a hierarchical prescribing regimen.AimsThe aim of this study was to assess the association of strength of pain-relief medication prescribed by the GP with the strength of previous prescription and pain level.MethodsThe PROG-RES study collected data on pain intensity in 428 patients aged ≥50 years with non-inflammatory musculoskeletal pain during a consultation with their GP. Prescriptions for analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) were identified on the day of the consultation and in the previous year and were classified as basic, moderate or strong analgesic or NSAID. Regression models were used to assess the association of strength of analgesia and prescription of a NSAID with the strength of previous prescription and the level of pain.ResultsThe majority of patients were not prescribed medication for their pain at the index consultation, but had such a prescription the previous year. There was an association between strength of analgesic and intensity of pain: more intense pain resulted in a stronger drug. This association was attenuated by adjustment for prescribed analgesia in the previous year. There was no association between intensity of pain and NSAID prescription, but previous NSAID prescription predicted another such prescription.ConclusionGPs do not always issue prescriptions for musculoskeletal pain. In cases where a prescription is issued, this is more strongly influenced by previous prescriptions than the patient's pain level. GPs adopt an individualized approach to the treatment of musculoskeletal pain in older adults.

Measures of juvenile fibromyalgia: Functional Disability Inventory (FDI), Modified Fibromyalgia Impact Questionnaire–Child Version (MFIQ‐C), and Pediatric Quality of Life Inventory (PedsQL) 3.0 Rheumatology Module Pain and Hurt Scale

Juvenile fibromyalgia (FM) is a chronic noninflammatory musculoskeletal pain condition typically diagnosed in adolescence. Juvenile FM is characterized by diffuse widespread pain, multiple painful tender points, sleep difficulty, fatigue, and other associated symptoms (1). Juvenile FM is also associated with considerable difficulty in physical, social, and emotional functioning (2–9). At present, there are no specific medical tests or disease markers to diagnose this condition, and assessment of symptoms and their impact is primarily by patient report. As noted by the Outcome Measures in Rheumatology Clinical Trials Fibromyalgia Syndrome Workgroup (10), a multidimensional assessment of FM syndrome is essential. Such an assessment should include measures of pain, fatigue, sleep, overall functioning, and quality of life. In patients with juvenile FM, research studies have traditionally utilized more generic pediatric measures that are applicable for many pain conditions. Only one measure has been specifically modified for use in juvenile FM: the Modified Fibromyalgia Impact Questionnaire– child version. In the following sections, we discuss 3 measures that can be used for assessment in juvenile FM, i.e., the Functional Disability Inventory (FDI), the Modified Fibromyalgia Impact Questionnaire– child version, and the Pediatric Quality of Life 3.0 Rheumatology Module Pain and Hurt scale. Measures used to assess pain characteristics, fatigue, and sleep used in pediatric pain disorders, including juvenile FM, are discussed in detail in the Measures of Pathology and Symptoms section in this issue.

The development of a new service for the management of Non-inflammatory Musculoskeletal Pain

Methods The business plan was developed by senior multidisciplinary members of the Rheumatology team. The new service was set up and then specific outcome measures were followed after 1 year to monitor the success and effectiveness of the treatments. Results The service was funded to employ af ull time Physiotherapist (PT), occupational therapist (OT), psychologist (Psych) and administrator. Outpatient appointments were established and patients were placed into the new service. The initial appointment was in a new-patient clinic and they were assessed by a Consultant paediatric Rheumatologist and a specialist physiotherapist. This initial assessment ensured that there was no other diagnosis other than a non-inflammatory condition such as hypermobility syndrome; the patient was then referred to PT, OT and Psych as appropriate. The treatments included individualised home muscle strength training programme, life style advice, group patient and parent education programmes and individualised pain management interventions. Specific Outcome measures (OCM) were used to monitor the success of the treatments provided. The most significant OCM’s were:  School attendance which increased from 75% missing at least 1 day a week due to pain to only 7%.  Loss of muscle strength in 98% of children which was resolved in 100% of those who completed the programme given.  Participation in PE also increased from 25% participating to 75% joining in sport at school.  The cost of providing the staff and facilities was only 30% of the revenue the service brought into the hospital. Conclusion The establishment of a dedicated service to the management of NIMPS has been shown to be both clinically and cost effective and has worked extremely well as an AHP led service enabling the medical staff to focus upon inflammatory diseases.

P.7.a.004 Psychiatric outcomes of girls with ADHD grown up: a controlled 11-year follow-up study

Distinguishing transient from persistent anxiety and depression symptoms in older people presenting to general practice with musculoskeletal pain is potentially important for effective management. This study sought to identify distinct post-consultation depression and anxiety symptom trajectories in adults aged over 50 years consulting general practice for non-inflammatory musculoskeletal pain.Self-completion questionnaires, containing measures of anxiety and depressive symptoms, age, gender, pain status, coping and social status were mailed within 1 week of the consultation and at 3, 6 and 12 months. Latent class growth analysis was used to identify anxiety and depression symptoms trajectories, which were ascertained with cut-off score ≥ 8 on Hospital Anxiety and Depression Scale subscales. Associations between baseline characteristics and cluster membership were examined using multivariate multinomial logistic regression analysis (the 3-step approach).Latent class growth analyses determined a 3-cluster anxiety model (n = 499) and a 3-cluster depression model (n = 501). Clusters identified were: no anxiety problem (44.1%), persistent anxiety problem (33.9%) and transient anxiety symptoms (22.2%); no depression problem (74.1%), persistent depression problem (22.0%) and gradual depression symptom recovery (4.0%). Widespread pain, interference with valued activities, coping by increased behavioral activities, catastrophizing, perceived lack of instrumental support, age ≥ 70 years, being female, and performing manual/routine work were associated with anxiety and/or depression clusters.Older people with non-inflammatory musculoskeletal pain are at high risk of persistent anxiety and/or depression problems. Biopsychosocial factors, such as pain status, coping strategies, instrumental support, performing manual/routine work, being female and age ≥ 70 years, may help identify patients with persistent anxiety and/or depression.

Discussing prognosis with older people with musculoskeletal pain: a cross-sectional study in general practice

BackgroundPrognosis has been described as an important but neglected branch of clinical science. While patients' views have been sought in the context of life-threatening illness, similar research is lacking for patients presenting with common, non-life-threatening musculoskeletal complaints. The aim of this study was to gauge whether and why older patients with musculoskeletal pain think prognostic information is important, and how often they felt prognosis was discussed in the general practice consultation.MethodsA cross-sectional survey of consecutive patients aged 50 years of over presenting with non-inflammatory musculoskeletal pain to 5 Central Cheshire general practices. The frequency of responses to the prognostic questions were described and the association with sociodemographic, presenting pain complaint, and psychosocial variables explored using logistic regression.Results502 participants (77%) responded to the postal questionnaire. 165 (33%) participants reported discussing prognosis in the consultation with their GP. Discussions about prognosis were more often reported by male patients (OR 1.72, 95% CI 1.09, 2.71) and those for whom this was their first consultation (OR 1.81, 95% CI 1.16, 2.80). 402 (82%) participants thought that prognostic information was important. This was highest among those currently in paid employment (OR 2.95, 95% CI 1.33, 6.57). The reasons patients gave for believing prognostic information was important included 'knowing for the sake of knowing' and planning future activity. Reasons for not believing prognostic information to be important included the belief that progression of pain was inevitable and that nothing could be done to help.ConclusionPrognostic information is thought to be important amongst older people with musculoskeletal pain yet discussions occur infrequently in primary care. Barriers to effective prognostic communication and the exact information needs of patients are still unknown and warrant further research.

Screening older people with musculoskeletal pain for depressive symptoms in primary care.

Older patients presenting to GPs with musculoskeletal pain are at high risk of having concurrent depression. To investigate the performance of ultra-short (1-4 items tools) screening questions used during the consultation, and through a patient questionnaire to detect depressive symptoms among older adults presenting with musculoskeletal pain to general practice. Cross-sectional survey, linked GP consultation data. General practices in central Cheshire, UK. Consecutive patients aged > or =50 years presenting with non-inflammatory musculoskeletal pain were eligible to participate. GPs screened all patients in the consultation for the presence of depressive symptoms using two questions. All patients were sent a postal questionnaire within 1 week of consultation containing the Hospital Anxiety and Depression Scale and the written version of the depression screening questions. The total number of patients included in the study was 428. In total, 35.5% of consulters had comorbid depressive symptoms, with 13.5% experiencing moderate or severe symptoms. Just over half of participants (n = 218/242; 51.4%) screened positive on self-administered screening at home compared with only 78 (20.8%) on GP-administered screening in the consultation. There was little difference between GP-administered and self-administered screening in the probability of depressive symptoms among those who screened positive with regard to exhibiting signs of having depressive symptoms. Older patients consulting their GP with musculoskeletal pain frequently have comorbid mental ill health. Ultrashort depression screening questions administered during the consultation miss a large number of those with depressive symptoms, including six out of eight patients with severe symptoms. An improvement in the performance of screening questions in this patient group or narrowing the definition of 'high risk' from all patients aged > or =50 years presenting with musculoskeletal pain could help to improve detection.

The Role of Peripheral Glutamate and Glutamate Receptors in Muscle Pain

Objectives: To review evidence that associates elevated muscle interstitial glutamate concentration and the activation of peripheral glutamate receptors with the development and maintenance of muscle pain in conditions such as myofascial temporomandibular disorders [TMDs].Findings: In certain noninflammatory musculoskeletal pain conditions, an association between pain, elevated glutamate concentrations and the expression of peripheral N-methyl-d-aspartate receptors [NRs] has been made. Myofascial TMDs are a noninflammatory muscle pain disorder characterized by pain and localized mechanical sensitivity in the masticatory muscle and a greater prevalence in young women than in men. Artificial elevation of glutamate concentrations in the masticatory muscles of healthy subjects evokes intense, short duration pain that is significantly greater in woman than in men and induces a more prolonged, localized mechanical sensitization that is similar in both sexes. Glutamate-evoked pain and sensitization may be attenu...

(637): Changes in nuclear protein expression in the RVM in an animal model of non-inflammatory musculoskeletal pain

(637): Changes in nuclear protein expression in the RVM in an animal model of non-inflammatory musculoskeletal pain

Concomitância de fibromialgia em pacientes portadores de hipotireoidismo e de alterações tireoideanas em pacientes com fibromialgia

INTRODUCAO: a fibromialgia (FM) pode ser definida como uma sindrome dolorosa musculoesqueletica nao-inflamatoria de carater cronico, tendo como sintomas mais comuns a fadiga e o sono nao-reparador. Tais manifestacoes podem nao resultar da FM, mas de outras doencas associadas, como o hipotireoidismo. OBJETIVO: descrever a ocorrencia de FM em pacientes com hipotireoidismo, e os casos de hipotireoidismo em pacientes com FM, alem de determinar os sintomas associados a essas condicoes clinicas. METODOS: foram avaliados 166 pacientes portadores de FM e 56 com hipotireoidismo. Os voluntarios responderam a um questionario para deteccao dos principais sinais e sintomas dessas doencas em estudo e foram submetidos as dosagens sericas de hormonio estimulador da tireoide (TSH), tiroxina livre (T4 livre) e anticorpo antitireoperoxidase (a-TPO). RESULTADOS: nos 166 pacientes com FM, foram diagnosticados hipotireoidismo clinico ou subclinico em 35 (21,1%). Dos 56 pacientes portadores de hipotireoidismo, em 36 (64,3%) foi confirmado o diagnostico de FM pelos criterios do American College of Rheumatology (ACR). Nos pacientes com hipotireoidismo previamente diagnosticado, a fadiga, o sono nao-restaurador e a cefaleia cronica foram estatisticamente mais frequentes naqueles que apresentavam diagnostico de FM. A rigidez matinal foi mais prevalente nos pacientes com hipotireoidismo sem FM. CONCLUSAO: ha que se considerar a presenca de manifestacoes clinicas ou laboratoriais de disfuncao tireoideana nos pacientes portadores de FM e de FM em pacientes portadores de hipotireoidismo, para uma melhor abordagem diagnostica e posterior tratamento dos mesmos.

Severity of musculoskeletal pain: relations to socioeconomic inequality

The main aim of the study was to investigate possible associations between severity of non-inflammatory musculoskeletal pain and residential areas of contrasting socioeconomic status. A 4-page questionnaire inquiring about musculoskeletal pain, and also physical disability, mental health, life satisfaction and use of health services was sent to 10,000 randomly selected adults in Oslo, Norway. For the purpose of this study, we analysed data from respondents living in two socioeconomically contrasting areas of the city. Measures of pain (intensity, duration, localisation), physical disability (MHAQ), mental distress (SCL-5, sleep disturbances), life satisfaction and use of health services (general practitioner, rheumatologist, medication, involvement in and satisfaction with own care) were compared between respondents living in the two areas ( n=870 and n=892 respondents, respectively) of whom 493 in each area reported non-inflammatory musculoskeletal pain. Multiple regression analyses adjusting for age revealed that living in the less affluent area was associated with strong and widespread pain, with high levels of physical disability and mental distress and with low life satisfaction. Living in the less affluent area was also associated with frequent use of analgesics and with low level of involvement in own health care, after adjustment for age, pain intensity and levels of physical disability and mental distress. Non-inflammatory musculoskeletal pain seems to be a more serious condition in a population living in a less affluent residential area compared with a more affluent one, even in an egalitarian society like Norway. Increased disease severity may thus amplify the impact of greater chronic morbidity in the disadvantaged part of the population. This should have implications for health care provision if the goal is treatment according to needs.

Clinical Update: Fibromyalgia Syndrome: Impairment and Disability Issues

Abstract Fibromyalgia is a perplexing, controversial syndrome with many unanswered questions regarding both etiology and manifestations and impairment and disability issues. This article reviews controversies attending this diagnosis, examines the debates concern etiology, explains why this diagnosis is unratable by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, and explore issues of disability. Health care professionals debate whether the diagnostic criteria actually define a distinct clinical disorder, but the American College of Rheumatology published, for research purposes, classification criteria for Fibromyalgia Syndrome (FMS) that since have been widely used: FMS has been defined as a complex, chronic condition characterized by widespread noninflammatory musculoskeletal pain, severe fatigue, and sleep disturbances. Many health care professionals maintain that FMS is best understood from a biopyschosocial perspective because of the absence of visible clinical signs and inability to confirm the condition by laboratory tests. FMS may affect between 3 and 6 million people in the United States, with a 10:1 predominance in women, most between 35 and 60 years of age. Section 18.3b, When This Chapter Should Not Be Used to Rate Pain-Related Impairment, advises that “the pain of individuals with ambiguous or controversial pain syndromes is considered unratable” and provides three discriminatory questions.

Involvement and satisfaction: A Norwegian study of health care among 1,024 patients with rheumatoid arthritis and 1,509 patients with chronic noninflammatory musculoskeletal pain

Involvement and satisfaction: A Norwegian study of health care among 1,024 patients with rheumatoid arthritis and 1,509 patients with chronic noninflammatory musculoskeletal pain

Involvement and satisfaction: a Norwegian study of health care among 1,024 patients with rheumatoid arthritis and 1,509 patients with chronic noninflammatory musculoskeletal pain.

To investigate involvement in and satisfaction with health care among patients with rheumatoid arthritis (RA) and persons with chronic noninflammatory musculoskeletal pain, to identify target areas for improvement. Data were collected from postal surveys carried out in 1994 in Oslo, Norway, with 1,542 patients with RA and 10,000 randomly selected adults. Patients with RA and persons with noninflammatory musculoskeletal pain were asked 3 questions about their involvement with treatment and 1 question about their satisfaction with health care. Levels of involvement and of satisfaction were related to demographic measures, health status measures, use of health services, and, for patients with RA, self-efficacy. Of the respondents with RA (n = 1,024), 40% scored low on at least 1 question on involvement and 11% reported global dissatisfaction. Being young, well educated, physically disabled, in good mental health, and self-efficient and having visited a rheumatologist in the last 12 months were associated with a high level of involvement; being female and having a low pain level, good mental health, and high self-efficacy were associated with satisfaction with health care. Of persons with noninflammatory musculoskeletal pain of more than 5 years duration (n = 1,509), 57% scored low on at least 1 question on involvement and 27% reported global dissatisfaction. Being well educated, having visited a general practitioner in the last 12 months, and having ever visited a rheumatologist were associated with a high level of involvement. Being older and having a low pain level and good mental health were associated with satisfaction. A low score on involvement was a strong independent predictor of global dissatisfaction in both groups. High education level and health service provided by rheumatologists were consistently associated with a high level of involvement. Good mental health and high involvement were associated with satisfaction with the care received. Efforts to achieve a higher level of patient involvement should especially be directed toward patients with low education, emotional distress, and a chronic physical disorder.

Alpha-like EEG activity in non-REM sleep and the fibromyalgia (fibrositis) syndrome

The occurrence and characteristics of alpha-like activity during non-REM (NREM) sleep were examined in 11 subjects suffering from non-inflammatory (non-rheumatoid) musculoskeletal pain — fibromyalgia (‘fibrositis’), and in 15 symptom-free controls. Both groups claimed to be good sleepers. Mean percentage alpha-like activity in sleep stages 2, 3, 4 and for NREM as a whole were greatest for the fibromyalgia group, but not significantly different from those of the controls. Overlap in the distribution of NREM alpha-like activity in sleep between the two groups indicated that it is not directly related to musculoskeletal symptoms. Spectral analyses showed a frontal area prevalence of this (kappa?) activity in the fibromyalgia group.

Long-Term Intermittent Hemodialysis

Two patients in whom renal function was virtually absent have been maintained on long-term intermittent hemodialysis for 20 months. Technical problems during dialysis were infrequent and the silicone rubber-Teflon arteriovenous shunts performed well. Major medical problems included a need for frequent blood transfusion with accompanying febrile reactions in one patient, uremic peripheral neuropathy, and intermittent bouts of noninflammatory musculoskeletal pain and stiffness. Hypertension was controlled by adequate ultrafiltration and hyperuricemia was well controlled by allopurinol, a drug which proved to be removed effectively by hemodialysis. Control of hyperkalemia between dialyses was facilitated by the presence of an increased fecal excretion of potassium. The performance of military corpsmen who were trained in all aspects of dialysis was highly satisfactory.