Rheumatology Pain Research Articles

281 The G.E.T. Going Group: a graded exercise therapy circuit class for rheumatology pain patients: outcomes of those completing the group, and survey of reasons for non-completion

281 The G.E.T. Going Group: a graded exercise therapy circuit class for rheumatology pain patients: outcomes of those completing the group, and survey of reasons for non-completion

Efficiency of the combination of physical therapy modalities with topical nonsteroidal anti-inflammatory drugs for treatment of pain in rheumatology

Pain is the most common syndrome in rheumatology. NSAIDs are often used in its treatment. But they have limitations associated with side effects. An advantage of topical drugs and physical factors (electrophoresis, phonophoresis) combination is the use of low doses of the drug and a decrease in time, to achieve a therapeutic effect, reduce the risk of adverse reactions, increase the concentration of the drug in the inflammation focus, prolonged action (creating a drug depot in tissues). Ketoprofen gel (“Artrocol gel”) is one of the representatives of this pharmacological group. Physicochemical properties help ketoprofen to penetrate easily through the skin and create a therapeutic concentration in the underlying tissues. 
 Objective. 
 To assess the effectiveness of ketoprofen gel (“Arthrocol gel”) electrophonophoresis in the treatment of pain in rheumatological patients. 
 Materials and methods. 
 The study was carried out on the basis of Physiotherapy Department of Vinnytsia Regional Clinical Hospital named after M. I. Pirogov. All patients treated according to the unified clinical protocols were divided into experimental group (EG) and control group (CG). Patients of EG (98 persons) underwent electrophonophoresis with ketoprofen gel once a day for a week. In CG (43 persons) ketoprofen gel was used without electrophonophoresis. The intensity of the pain syndrome is monitored using a visual analog scale (VAS) of Huskisson at rest and during movement. A week later, the patient and the doctor evaluated satisfaction with the results of treatment on the scale: not effective, insufficient, satisfactory, good, excellent. 
 Results. 
 There was a persistent decrease in the intensity of pain syndrome in patients of both groups. The VAS scores were lower in the EG starting from the 3rd day of treatment. The intensity of the acute pain syndrome after 1-week treatment at rest (t = 4.71, p < 0.001) and during the movement (t = 3.84, p < 0.001) more decrease in EG. Satisfaction with the results of treatment was higher in EG.

High lumbar disc herniation coexisting with thoracic meningioma – an issue of differential diagnostic

Abstract Meningiomas involving the spinal compartment are relatively rare compared to the intracranial ones representing between 7,5% and 12,5% of all CNS meningiomas, most of them being located in the intradural compartment respecting the pial layer of the spinal cord. Affecting ten times more often women rather than men, especially in the 5th and 6th decade of life, they pose a difficult diagnostic setting despite modern neuroimagistic techniques. The matter of correct differential diagnosis becomes even more doubtful, most of the patients of that age having also associative degenerative disorders, e.g. lumbar disc herniation. In this case proper neurological examination is the key as we will furthermore demonstrate - the MRI exam being targeted on the level of the sensorial dysfunction and not on the most common region which gives according pathology. The following case presentation can be considered “classic” representing a patient with all the criteria mentioned above including a long history of rheumatologic and chronic back pain medication for pain relief. We used the Frankel Scale for grading the pre- and postoperative neurological status. Acute neurological deterioration (under 24 hours) is an important criteria for admission in emergency unit with around the clock exploration followed by microsurgical operation for the best possible outcome. Coexisting chronic lesions may be left behind and kept under surveillance, operated only when clear signs of health disorder appear. Because there are reported cases of thoracic meningiomas discovered after hernia disc operation and even cases of paraplegia due to a missed lesion, the aim of this article is to emphasize the importance of proper neurological examination preceding any MRI exploration.

Chronic neck pain and anxiety-depression: prevalence and associated risk factors.

IntroductionChronic pain in rheumatology often has a psychic impact, which may aggravate the daily life of patients. Chronic neck pain, as an example, is a frequent reason for consultation. The aim of this study is to assess the prevalence of anxiety and depression in patients with neck pain, and identify risk factors associated with their occurrence.MethodsIt was a cross-sectional study that concerned 80 patients with neck pain lasting for more than 3 months, seen in rheumatology consultations. All patients with symptomatic neck pain or psychological history or receiving psychotropic medication were excluded from the study. For each patient, we determined the sociodemographic characteristics and clinical ones. The anxious and depressed mood was assessed by the Hospital Anxiety and Depression Scale (HAD).ResultsOf the 80 patients, 67 (83.8%) were women. Average age of our population was 51.8± 11.8 years. Median duration of symptoms was 24 months [12, 48]. Mean VAS pain was 63.9% ± 12.5, mean VAS functional discomfort was 60.9% ± 14.2 and mean VAS disability was 59.8% ± 14.7. 32 patients (40%) were illiterate and 18 (22.5%) had university level. Anxiety was found in 54 (68.4%) and 44 (55.7%) patients were depressed. In univariate analysis, VAS disability was statistically linked to anxiety (OR:1.05; 95%CI: 1.01-1.08; p = 0.02). The cervicobrachial neuralgia (CBN) was significantly associated with depression (OR: 3.33; 95%CI: 1.20-9.23; p = 0.02). Primary education level had a statistically significant relationship with anxiety (OR: 6.00; 95%CI: 1.03-34.84; p = 0.04) and depression (OR: 5.00; 95%CI: 1.09-22.82; p = 0.03). In multivariate analysis, VAS disability and CBN were independently associated with anxiety and depression respectively.ConclusionThis study underlines the fact that anxiety and depression are prevalent in chronic neck pain (CNP) patients. Furthermore, disability and CBN which are linked to CNP can predict which patient is at higher risk of psychological distress.

What Musculoskeletal (MSK) Conditions are Referred from Routine General Practice (GP) and what Impact does this have on Developing Innovative Care Models for Patients with MSK Conditions in Primary Care?

Introduction: The current ethos within the United Kingdom (UK) health system is to encourage community management of health problems, increasing primary care workload. Yet General Practice (GP) is currently in ‘crisis’ with significant workload pressures. GP Federations have been developed to allow more collaborative working between GP practices and help develop new innovative models of care to better manage the GP workload pressures. Musculoskeletal(MSK) conditions constitute approximately 20% of General Practice(GP) consultations and therefore the Belfast GP Federation aimed to assess the demand for MSK conditions to allow development of new primary care-based treatment pathways for these conditions. The aim of this paper is therefore to assess the demand for orthopaedic, rheumatology and chronic MSK painful conditions by assessing the referrals from 2 GP practices and the referrals to one orthopaedic Integrated Clinical Assessment and Treatment services (ICATs) clinic for these conditions and then propose innovative models of care to manage this demand within the community. Methods: Secondary care referral rates for two urban GP surgeries in the Belfast area were assessed in April, 2016 to orthopaedics, rheumatology and chronic pain clinics. The referrals to an orthopaedic ICATs clinics, staffed by one GPwSI in MSK, in May 2016 were also reviewed. The orthopaedic ICATs team receive referrals from GPs regarding musculoskeletal conditions and this particular service is based in the Southern Trust area of Northern Ireland. Results: Overall from the 2 GP surgeries there was 59 orthopaedic referrals, 11 to rheumatology and 3 to the chronic pain clinic. The commonest joint referred to the orthopaedic clinic was knee (15 referrals, 25.4%) and the commonest reason to refer to rheumatology was to exclude an inflammatory arthritis (6 referrals, 54.5%). There was then 25 referrals to ICATs, with the commonest reason for referral being neck (6 referrals, 24%) and back (4 referrals, 16%). The commonest treatment options employed within the ICAT service included joint injections (8 patients, 32%) with referral to in-house physiotherapy (8 patients, 32%). Conclusions: UK GP is currently under significant workload pressures and musculoskeletal conditions, including orthopaedic, rheumatology and chronic painful conditions, make up a significant proportion of this workload. The main musculoskeletal areas which GPs are referring to secondary care include knee and spinal conditions. To help better manage this workload within primary care we propose developing a new community-based monthly musculoskeletal clinic based within local GP surgeries, supported by a MSK educational programme open to all GPs in the area. Outcomes which will be monitored from this quality improvement work will include secondary care referrals and maintaining high patient satisfaction as well as improving GP confidence in managing MSK conditions.

Fibromyalgia with severe forms of progression in a multidisciplinary therapy setting with emphasis on hyperthermia therapy--a prospective controlled study.

IntroductionFibromyalgia syndrome (FMS) is a multi-factorial disease involving physiological as well as psychological factors. The aim of the study was to investigate a multidisciplinary inpatient treatment with emphasis on hyperthermia therapy by patients with widespread pain.Materials and methodsThe study involved 104 patients suffering from severely progressive FMS. A convenience sample and a prospective cohort design were used. The patients were treated in an acute hospital focusing on rheumatologic pain therapy and multidisciplinary complementary medicine. One patient group was treated with inclusion of hyperthermia therapy and the other group without. The therapy density (number of performed therapies per patient) was determined for every patient. Functional capacity measured by the Hannover functional status questionnaire (Funktionsfragebogen Hannover) and symptoms (von Zerssen complaint list) were analyzed for both groups on admission and on discharge.ResultsOn admission, no significant difference could be established between control group (CG; multimodal without hyperthermia) and hyperthermia group (HG; multimodal with hyperthermia) (functional capacity, P=0.936). Functional capacity improved for the CG and the HG. On discharge, there was a significant difference between the two groups (functional capacity, P=0.039). There were no significant differences in fibromyalgia symptoms between CG (mean 41.8) and HG (mean 41.8) on their admission to hospital (P=0.988). On discharge, there was a significant difference (P=0.024) between the two groups (HG, mean 30.6; CG, mean 36.6). The inpatient therapy of patients with severely progressive fibromyalgia is characterized by a high frequency of therapy input.ConclusionFMS, especially with severe progression and a high degree of chronification, demands a multidisciplinary approach. In addition to the use of complementary medical procedures, integration of hyperthermia in the treatment process is a useful option.

Physiopathology of pain in rheumatology.

Pain is the main manifestation of many rheumatic diseases (be they overtly inflammatory such as rheumatoid arthritis or dysfunctional such as fibromyalgia) but, at least initially, the mechanisms involved in the genesis, amplification and chronicisation of the persistent pain characterising the various conditions can be very different. The main peripheral mechanism underlying acute nociceptive pain is a change in the activity of the nociceptors located in the affected anatomical structures (joints, tendons and ligaments), which makes them more sensitive to normally painful stimuli (hyperalgesia) or normally non-painful stimuli (allodynia). This physiopathological mechanism of peripheral sensitisation plays a primary role in rheumatic diseases characterised by acute inflammation, such as the arthritides due to microcrystals. In the case of chronic rheumatic diseases that do not regress spontaneously, functional and structural central nervous system changes cause a generalised reduction in the pain threshold that is not limited to the anatomical structures involved, thus leading to the appearance of hyperalgesia and allodynia in many, if not all body districts. This is the physiopathological basis of chronic, widespread musculoskeletal pain.

Costs of pain in rheumatology.

Chronic pain has been identified as an important issue related to various rheumatic diseases. At the time of a major government spending review, it is appropriate to discuss the pain characterising rheumatic diseases and its related costs. It is clearly essential for healthcare authorities to rationalise their policies on the basis of the increasing expectations of the users of healthcare services while simultaneously balancing their books. There are few published studies concerning the costs of pain of any kind, and the same is true of the costs of the chronic pain associated with diseases such as rheumatoid arthritis, osteoarthritis, and fibromyalgia.

AB0872 Chronic Neck Pain and Anxiety-Depression: Prevalence and Associated Risk Factors

BackgroundChronic pain in rheumatology often has a psychic impact, which may aggravate the daily life of patients. Chronic neck pain, as an example, is a frequent reason for consultation.ObjectivesTo assess...

SP0093 Management of Pain - A Mechanism Based Approach

Pain is according to the widely accepted IASP definition “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. Acute...

300. Attending a Pain Management Programme Reduces Hospital Investigations, Appointments and Interventions Over the Next Three Years

Background: Patients with chronic musculoskeletal pain are often frequent attenders at GP surgeries and hospitals. Previous research showed that patients attending our rheumatology pain clinic at University College London Hospitals (UCLH) had poor self-efficacy despite multiple previous interventions and investigations. Continuing this pattern of healthcare use is ineffective. Pain management programmes (PMP) based on cognitive behavioural therapy seek to help patients to accept that the chronic pain cannot be cured and thus to engage coping strategies to improve quality of life. We sought to investigate whether attending a pain management programme reduced the number of hospital appointments, interventions and investigations over a three year period. Methods: We reviewed the medical records of 74 patients who had attended the pain management programme at the National Hospital for Neurology and Neurosurgery, London in 2008–9. We recorded the numbers of hospital appointments, interventions (injections, physiotherapy, and acupuncture) and investigations (X-rays, scans, EMG but excluding blood tests) over the 3 years before the programme and the 3 years after it. We also recorded demographic data and main diagnosis for each patient. Results: Of the 74 patients, 60 were women and 14 were men. Mean age was 45 years (range 19–74). All types of hospital encounter were reduced in the 3 years following the PMP compared with the 3 years before, as shown in Table 1. These reductions were seen equally in men and women and equally in people over and under 45 years old. 29 patients had joint hypermobility syndrome and attended a modified JHS-specific PMP. Similar reductions in appointments, investigations and interventions were seen in JHS and non-JHS patients. Conclusion: Attending this pain management programme led to a decrease in hospital appointments, investigations and interventions in people with chronic musculoskeletal pain. This has implications for cost-effectiveness of such programmes as they potentially reduce ineffective use of healthcare resources.

PReS13-SPK-1127: Pediatric rheumatology in India

Pediatric Rheumatology took birth in India with the formation of an interest group of the Indian Academy of Pediatrics and the first conference in 2001 in Mumbai. Now 11 conferences old, it has about 200 members and 12 centers offering part time or whole time care. With a population of over 1000 million, it may be extrapolated from Western data that India should have at least 400000 children with rheumatologic disease - JIA, JDM, SLE and vasculitides (excluding KD and HSP) Disease patterns are similar to a Western clinic and a little over a third of children attending a rheumatology clinic in Mumbai are diagnosed to have non rheumatologic musculoskeletal disease, notably leukemia, genetic disorders and chronic pain syndromes. The term 'musculoskeletal medicine clinic' seems more apt. Acute diseases such as septic arthritis/osteomyelitis are probably filtered at the primary care level and hence the clinic functions mainly as a chronic or day care facility. Fluorosis, musculoskeletal MDR tuberculosis, brucellosis and HIV associated arthropathy are unique issues. Most centers report declining trends of Rheumatic fever but an alarming increase of KD with consequent IViG requirement. Rare diseases such as hereditary fever syndromes are seen, some possibly representing the vestiges of early European colonization. Individual trends differ with SOJIA and ERA forming the bulk of JIA rather than OJIA. Uveitis is not a major concern. Outcomes of individual diseases seem different to the West with most centers in India reporting a milder phenotype of JDM. Paradoxically 80% of the world's pediatric rheumatologists care for 20% of the world's children and vice versa. Our undergraduate teaching ignores rheumatology while our post graduate teaching focuses more on acute cross sectional care rather than chronic longitudinal care. Patents usually reach through complex pathways of referral, often having consulted adult orthopaedic surgeons or alternative medicine systems prior to their visit, highlighting the need for increasing awareness about our specialty to lay public. They often have to travel 300-500 km for a consultation. Consequently, delay in diagnosis of various diseases, irregular follow up and frequent usage of steroid prior to referral are common. While raising money for one time use of IViG is still feasible (selfpaid or charity), a country with a per capita income of 1219 USD and much larger problems is unable to adapt treatment guidelines suggested by the West when it comes to the use of biologicals and consequently lesser studied drugs and treatment algorithms are resorted to. The crunch for interested and trained personnel (at least 200) has been addressed through a 3 level process -Preach -sensitizing large gatherings of pediatricians, Reach and Teach-intensive weeklong courses to committed smaller groups and Each to Each -one on one teaching through fellowships. The results are slow but visible. India can contribute to the world of pediatric rheumatology through its sheer numbers and its English speaking medical community thus providing an excellent collaborative research and teaching opportunity to centers with knowhow but lacking in numbers. The developed world can help us through facilitating student exchange, concessional diagnostic tests and courses, telemedicine, bulletin board, Asian editions of books or open access publications and patient information.

SP0070 Pain management in rheumatology – lessons from a pain in motion: From the joint to the brain, from analgesics to biologics

Pain in rheumatology represents a frequent situation. For many years it has been considered as the prototypical nociceptive pain condition but recent findings may modify pathophysiological and treatment approaches.1. Recent...

Qualitätskontrolle der Rheumatologischen Interdisziplinären Schmerz-Sprechstunde

The Rheumatologic Interdisciplinary pain assessment (RIPA) was evaluated for the time period between February 2002 and December 2005 by Scascighini and Sprott in 2007. The objective behind this quality control (performed for the time period from January 2006 through June 2010) was to analyse differences between employed and unemployed patients. Patients were interviewed in a longitudinal profile with a follow-up of three months after the interdisciplinarian evaluation (including medical, physio/occupational therapy as well as psychological evaluations). Client management for the group of currently unemployed persons was simplified for 63.8% of referring doctors following these consultations hours. With the group of currently employed persons it even facilitated client management for 79.2% of referring doctors, subsequent to consultation hours. 92.5% of these referring doctors would recommend the RIPA to colleagues and interested parties.

Report of the American College of Rheumatology Pain Management Task Force

Report of the American College of Rheumatology Pain Management Task Force

P02-210 Depression, anxiety and sleep disorders in patients with chronic rheumatic pain

Aims:Chronic pain irrespective of its origin can be a major factor of significant distress inducing high levels of anxiety, depression and sleep disturbance. These symptoms can, by their turn, aggravate the perception of pain. The objective of this study is to characterize mood, anxiety and sleep pattern in patients with chronic rheumatic pain.Methods:Patients observed in the Psychosomatic Consultation of Coimbra University Hospitals from January 2008 with chronic rheumatologic pain were included in the study. They were prospectively assessed (twice in average) by a Psychiatrist for mood, anxiety, sleep, general status and levels of pain with standardized rating scales.Results:Thirty-two female patients were included in the study. Mean age was 51,22±7,37 years. Depression and levels of anxiety both correlated positively with Clinical Global Impression Scale but not with the level of pain reported by the patient. Moreover, although a significant proportion of the patients reported sleep disturbance, especially in the beginning and in the middle of the night, this was not correlated with levels of pain.Conclusions:This study suggests that chronic pain is not a predictor of depression and anxiety and does not fully explain the distress reported by patients with chronic rheumatic disorders. Assessment of other factors such as personality traits, coping styles and maladaptative health behaviours should be part of the routine intervention in these subjects.

Antiepileptic drugs to treat pain in rheumatic conditions. Recommendations based on evidence-based review of the literature and expert opinion

Objectives Neuropathic pain is commonly encountered in rheumatology practice, often associated with nociceptive mechanisms. It is caused by nervous system lesions, and the usual treatments with analgesics and anti-inflammatory drugs are mostly ineffective. Antiepileptic drugs (AED) have proved effective in relieving neuropathic pain. AED are recently used by rheumatologists since the role of neuropathic pain in rheumatological conditions has only recently been documented. Nevertheless, the tendency seems to be reversed when these drugs are used inappropriately. The CEDR ( Cercle d'Etude de la Douleur en Rhumatologie), a specific interest group of the French Society of Rheumatology that focuses on pain in rheumatology, undertook to develop recommendations for the use of AED in Rheumatology. Methods A list of questions concerning the prescription of AED in painful rheumatic conditions was validated by a working group of 7 experts from the CEDR. The list of questions was used to draw up the recommendations. A literature review was performed using electronic databases (Medline, Embase and Cochrane library between 1980 and 2007) without limitations on the type of publication: case reports, clinical trials, literature review and guidelines about therapeutic management of neuropathic pain. Selected studies were scored for quality. Based on the literature and clinical experience, recommendations were developed using the Delphi method. Results We identified 29 studies concerning the use of AED in painful rheumatic conditions and 16 studies were considered valid and scored for quality. These few studies, the guidelines published for neuropathic pain treatment and the clinical experience of each expert, were used to develop 11 recommendations for the use of AED in painful rheumatic conditions. Conclusion These recommendations can be used as guidelines to help prescribers to use AED for the management of pain in rheumatic conditions until further scientific evidence becomes available.

P66 Pain in rheumatology—overview in rural West Bengal

P66 Pain in rheumatology—overview in rural West Bengal

Factors affecting self-efficacy and pain intensity in patients with chronic musculoskeletal pain seen in a specialist rheumatology pain clinic

Chronic musculoskeletal pain is a very common and costly health problem. Patients presenting to rheumatology clinics with chronic pain can be difficult to manage. We studied 354 patients referred to a rheumatology chronic pain clinic over 5 yrs to identify factors affecting their self-efficacy and intensity of pain. We collected data for each patient, covering demographic and psychosocial factors, characteristics of their pain and previous treatment. We measured self-efficacy using a validated questionnaire, and pain intensity (PI) on an NRS. We performed multiple regression analysis to determine as to which factors were independently associated with these outcomes. Despite extensive previous investigations and treatment, these patients had low self-efficacy [median = 26.5, interquartile range (IQR) 15-38, best possible = 60] and high PI scores (median = 7, worst possible = 10, IQR 5-9). Low self-efficacy was most clearly associated with depressive symptoms and not being employed. PI was most clearly associated with depressive symptoms, extensive pain and lower level of education. Community-based studies suggest psychosocial factors are very important in determining outcomes in patients with chronic pain. This study suggests that the same is true in patients referred to rheumatologists due to chronic musculoskeletal pain and that these factors-particularly depressive symptoms and not being employed-are more important than site or duration of pain in those patients.

Trial of a new pain assessment tool in patients with low education: the full cup test

Pain is subjective and pain assessment depends on the patient's self-report. The measurement of pain needs simple tools, especially in patients with low education. There are limited reports about pain assessment in this type of patient. The aims of the present study were to develop a pain scale that is easy for patients with low education to understand and to evaluate its usefulness in these patients. A total of 128 adult non-demented patients presenting with headaches or rheumatologic pain were included in this study. The first phase of the study involved 114 patients and aimed to estimate the usefulness of the full cup test (FCT) compared with the visual analogue scale (VAS). The second phase of the study involved 23 patients with headaches selected randomly from the 114 patients and assessed the usefulness of the FCT for detecting changes in pain levels. The third phase of the study involved 14 patients with low education suffering from headaches and examined the usefulness of the FCT in these patients. The mean VAS and FCT scores were statistically correlated and reliable and did not differ significantly. Patients with low education understood the FCT more easily than the VAS. We concluded that the FCT is useful for both assessing and differentiating changes in pain, and is suitable for assessing pain in patients with low education.