chronic widespread pain joost dekker department of rehabilitation medicine vu university medical...
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Chronic Widespread Pain
Joost Dekker
Department of Rehabilitation Medicine
VU University Medical Center
Amsterdam, the Netherlands
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Overview
Chronic Widespread Pain (CWP)
– Definition, assessment, epidemiology
– Psycho-biology
– Cognitive factors maintaining CWP
– Treatment of CWP
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Definition
• Pain
– In at least two contra-lateral limbs
&
– in the axial skeleton
&
– for at least 3 month
ACR, 1990
• Fibromyalgia
– Tenderpoints
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Assessment
Hunt, Rheumatology, 1999
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Assessment
• "Have you suffered from general pain during the last 3 months?"
• "Did you have continuous pain during all 3 months?"
• "Do you suffer from pain in both the upper and lower body?"
• "Do you suffer from pain in both the right and left sides?”
Kato et al., Arch Intern Med. 2006
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Epidemiology
• Prevalence
– 1 month population prevalence ~ 11 %
Croft, 1999
• Comorbidities
– Fatigue
– Arthritis
– Depression and anxiety
– IBS
– Allergy
Kato, 2006
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Framework
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Framework
Biological and psychological mechanisms
Central sensitisation
o Paino Fatigue
Figure 1 Central sensitisation and CWP
o Activity limitations
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Framework
Biological and psychological mechanisms
Central sensitisation
o Paino Fatigue
Figure 2 Cognitive factors maintaining CWP
o Activity limitations
Cognitive factors:o Self efficacyo Cognitive coping strategies, including fear avoidance o Illness beliefs
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Framework
Biological and psychological mechanisms
Central sensitisation
o Paino Fatigue
Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP
o Activity limitations
Multidisciplinary rehabilitation
Cognitive factors:o Self efficacyo Cognitive coping strategies, including fear avoidance o Illness beliefs
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Framework
Biological and psychological mechanisms
Central sensitisation
o Paino Fatigue
Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP
o Activity limitations
Multidisciplinary rehabilitation
Cognitive factors:o Self efficacyo Cognitive coping strategies, including fear avoidance o Illness beliefs
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Central sensitization
Increased excitability of spinal and supraspinal neural circuits
• Hyperalgesia
– Noxious stimuli result in more pain than expected
• Allodynia
– Nonnoxious stimuli result in pain
• Radiation
– Spreading of pain
• Temporal summation
– Increased latency, after sensation
Bennet, 1999
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Major neural pathways in pain processing
Bennett R and Nelson D (2006) Cognitive behavioral therapy for fibromyalgia Nat Clin Pract Rheumatol 2: 416–424 doi:10.1038/ncprheum0245
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Framework
Biological and psychological mechanisms
Central sensitisation
o Paino Fatigue
Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP
o Activity limitations
Multidisciplinary rehabilitation
Cognitive factors:o Self efficacyo Cognitive coping strategies, including fear avoidance o Illness beliefs
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Risk factors
• Depression
– Predicts onset of episode of pain
Carroll, 2004
• Somatic symptoms and illness behavior
– Predict onset of CWP McBeth, 2001
• Trauma
– Separation from mother, or institutionalized as child predict onset of CWP in adulthood Jones, 2008
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Risk factors
• Impaired sleep
– Predicts onset of pain Canivet, 2008
– Predicts intensity of pain in CWP Bigatti, 2008
• Restorative sleep
– Predicts resolution of CWP Davies, 2008
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Impaired sleep Canivet, 2008
• Cohort
– 45 – 65 years
– Baseline questionnaire
– Exclusion of subjects with shoulder, neck, lumbar pain
– Exclusion of subjects with medical conditions interfering with sleep
– Follow up after 1 year
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Impaired sleep Canivet, 2008
• 1 year risk of chronic pain
– 14.6% in women
– 11.8% in men
• Sleeping problems
– 11.2% women
– 7.6% men
• Association ‘sleeping problems’ and ‘chronic pain’, controlling for confounders
– OR= 1.92 in women
– OR= 1.83 in men
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Risk factors for CWP
Depression
Somatic symptoms and illness behavior
Trauma
Impaired sleep
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Biological mechanisms
• Hypothalamo-pituitary adrenal axis (HPA-axis):
“stress system”
– Dysfunction of HPA-axis predicts onset of CWP
McBeth, 2007
• Autonomic nervous system ?
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HPA-axis McBeth, 2007
• Cohort
– Baseline questionnaire
– Exclusion of subjects with CWP
– Selection of subjects at risk for CWP
• Somatic symptoms and illness behavior
– Assessment of HPA-axis, at baseline
– Follow up after 15 months, questionnaire
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HPA-axis McBeth, 2007
• Onset of CWP at follow up
– 11.6%
• Influence of baseline HPA-axis
– Subjects with CWP, compared to subjects without CWP
• Higher cortisol level (post-dexamethasone)
• Lower cortisol level in morning saliva
• Higher cortisol level in evening saliva
Dysfunction of HPA axis predicts onset of CWP
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Summary 1
• Risk factors for CWP
– Depression
– Somatic symptoms and illness behavior
– Trauma
– Impaired sleep
• Biological mechanisms
– HPA-axis
– Autonomic nervous system ?
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Framework
Biological and psychological mechanisms
Central sensitisation
o Paino Fatigue
Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP
o Activity limitations
Multidisciplinary rehabilitation
Cognitive factors:o Self efficacyo Cognitive coping strategies, including fear avoidance o Illness beliefs
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Cohort study
• Goal
– To predict outcome of multidisciplinary rehabilitation in CWP, using psychological processes maintaining CWP
• Patients
– CWP
– Aged > 18 and <75
• Assessment at
– Pretreatment, 4 months post, 15 months post
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1st Results
• Cognitive concepts are considered to be separate entities, but are they ?
– “Different psychological concepts related to pain may overlap and represent the same domain” Nielson and Jensen, 2004
– “There is a need for developing more comprehensive and integrative conceptual models” Keefe et al., 2004
• Goal: To explore overlap between cognitive concepts maintaining chronic pain derived from different models and to reduce these concepts into a more parsimonious model
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Cognitive factors maintaining CWP
Self-efficacy
– One’s confidence in performing a particular behavior and overcoming barriers to that behavior (Bandura).
I can always manage to solve difficult problems, if I try hard enough
Illness perceptions
– Ideas that patients hold about their illness (Leventhal)
My pain will last for a long time
I can do a lot to control and manage my pain
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Cognitive factors maintaining CWP
Coping
– Cognitive efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person (Lazarus and Folkman)
When I have pain I try to think about something nice
Kinesiophobia / Fear-avoidance
– Episode of pain can be interpreted as a signal for future pain and injury, resulting in pain-related fear and avoidance of activity (Lethem).
It is not safe for a person with a condition like mine to be physically active
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Method
• Measures
– Self-efficacy
• Dutch General Self-efficacy Scale (DGSS)
– Illness perceptions
• Illness Perception Questionnaire-Revised (IPQ-R)
– Cognitive coping styles
• Dutch Coping with Pain Questionnaire (CPV)
– Kinesiophobia
• Tampa Scale of Kinesiophobia (TSK)
• Factor analysis
– Explorative, Orthogonal
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Results
• N = 134
• 92.5% women
• Age: 46 ± 11 years
• 75.4% Dutch ethnicity
• Pain (0-10): 6.2 ± 2.1
• Fatigue (0-10): 8.3 ± 1.6
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Results of factor analysis
Scales Factors
Negative emotional cognitions
Active cognitive coping
Control beliefs and
expectancies of chronicity
IPQ Personal control -.43
IPQ Treatment control -.40
IPQ Illness coherence .55
IPQ Consequence .55 .43
IPQ Emotional representation .77
IPQ Timeline .67
IPQ Timeline cyclical .54
CPV Catastrophizing .63
CPV Perceived pain control .45 -.49
CPV Denial pain sensations .76
CPV positive self statements .77
CPV Reinterpreting pain .67
CPV Praying and hoping .65
CPV Diverting attention .75
TSK Fear and avoidance .59
DGSS General self efficacy -.58
Eigenvalue 3.5 2.7 1.4 Explained variance 22.2% 16.9% 8.5%
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Summary 2
• Variety of cognitive concepts maintaining CWP can be reduced to
negative emotional cognitions
active cognitive coping
control beliefs and expectancies of chronicity
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Biological and psychological mechanisms
Central sensitisation
o Paino Fatigue
Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP
o Activity limitationso Depression
Multidisciplinary rehabilitation
Cognitive factors:o Self efficacyo Cognitive coping strategies, including fear avoidance o Illness beliefs
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Treatment
• EULAR recommendations for management of fibromyalgia
– Systematic review of high quality studies
– Delphi procedure
Carville, 2008
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EULAR: non-pharmacological management
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EULAR: pharmacological management
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Multicomponent treatment of fibromyalgia
• Multicomponent
– At least 1 educational therapy + at least 1 exercise therapy
• Systematic review
• Strong evidence for short effect of multicomponent treatment on
– Pain
– Fatigue
– Depressive symptoms
– QoL
– Self efficacy pain
– Physical fitness
Hauser, 2009
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Summary 3
• Treatment
Nonpharmacological
Pharmacological
Multicomponent
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Framework
Biological and psychological mechanisms
Central sensitisation
o Paino Fatigue
Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP
o Activity limitations
Multidisciplinary rehabilitation
Cognitive factors:o Self efficacyo Cognitive coping strategies, including fear avoidance o Illness beliefs