ADVERSE EVENTS IN CHILDHOOD AND CHRONIC WIDESPREAD PAIN IN ADULTHOOD: A TRUE ASSOCIATION?
Macfarlane GJ. McBeth J, Morris S, Benjamin S', Silman AJ. Arthritis Research Campaign Epidemiology Unit and 'Dept of Psychiatry, Univ of Manchester Medical School, Manchester, Ml 3 9PT.
Background: It is unknown whether the observed relationship between chronic widespread pain in adults and adverse childhood factors, observed in clinic populations, holds in the general population and whether these associations are a result of differential recall.
Aim of Investigation: Firstly to examine amongst subjects at risk of future chronic widespread pain whether adverse childhood factors farther increases risk. Secondly to determine whether there is differential recall of adverse childhood factors between subjects with and without pain.
Methods: From a random sample of persons participating in a population survey (75% participation rate), 296 subjects who responded to a postal survey and were at risk of having CWP (General Health Questionnaire score S 2) were recruited. Subjects participated in a structured psychiatric interview (PSE-10), and were questioned on the occurrence of 14 adverse experiences occurring before the age of 16 years. Medical records relating to childhood were examined for reports of hospitalisations and operations.
Results: When compared to those subjects with no pain, there was an increased risk of current CWP (American College of Rheumatology criteria) of between 2- to 5-fold amongst those reporting an adverse event in childhood. Associations with CWP were limited to those with a mental disorder e.g. reports of illness in childhood (OR = 2.8, 95% CI (0.5-18)), illness in family members (OR =3.1, 95% CI (1.1-8.3)), parental loss (OR = 2.4 95% CI (0.6-9.4)), and abuse (OR=8.6 95% CI 0.96-84). In those with no mental disorder there was no association. After adjusting for errors in reporting (from examining medical records), observed relationships between hospitalisations, operations and CWP were no longer evident
Conclusion: Self-reported adverse events occurring in childhood are associated with CWP and appear to be mediated through mental disorder. Validation of self-reported exposures suggests that there may be differential recall of past events amongst those with and without pain.
Acknowledgments: Supported by a grant from the Arthritis Research Campaign S0542.
COGNITIVE IMPAIRMENT AND HYPERVIGI. LANCE IN FIBROMYALGIA
E. Masquelier and J. Grisart, Centre d'Algologie, Cliniques Univer-iitaires Saint-Luc, 1200 Brussels, Belgium.
Aim of the Investigation: Among other signs (e.g. diffuse pain), fibromyalgia is associated with a state ofhypervigilance, i.e., an increased attention to (bodily) sensations. As pain perception consumes attention and as attentional resources are limited, hyper-yigilance would have as correlate, a higher distractibility in fibromyalgia patients. This may result in worsened cognitive performances in these patients as compared to patients with localized pain in whom no hypervigilance is expected. It is here assumed :hat the selective impact of chronic pain on the controlled proc-ssses (attention-demanding) rather than on the automatic processes [no or little attention is required) would be increased in fibromyalgia patients when achieving a mental task.
Methods: Eighteen patients with chronic localized pain (LP), 17 fibromyalgia patients (FP) and 21 healthy subjects (HS) participated to a cued recall task based on the Process Dissociation Procedure (Jacoby, 1991). This procedure is a method for estimating separately the within-task contributions of the controlled strategies and of the automatic processes operating in this task.
Results: The contribution of the automatic processes to this cued recall task is equal across the three groups (p = 0.10). However, controlled processes significantly decrease as a function of the bodily extent of chronic pain (HS>LP ; p = 0.048 / LP > FP ; p = 0.01). Moreover, within groups comparisons show that, if controlled processes contribute more to the cued recall than the automatic processes in HS (p = 0.045), LP have no preferential strategy. As expected in FP, controlled processes participate very little to the responses contrary to the automatic processes (p== 0.0002).
Conclusions: These findings show a negative relation between the bodily extent of chronic pain and the controlled processes in memory. This suggests a higher attentional cost for diffuse pain: these observations may be related to a state ofhypervigilance.
PREDICTORS OF GENERALIZED SOMATOSEN-SORY HYPERVIGILANCE IN CHRONIC PAIN PATIENTS.
AJ McDermid* and GB Rollman(SPON: RF Schnurr), Dept of Psychology, The Univ of Western Ontario, London, Ontario Canada N6A 5C2
Aim of Investigation: Generalized somatosensory hypervigilance (GSHV) is a perceptual style which is characterized by an exaggerated response to aversive somatosensory stimuli which has been observed in some chronic pain patients who have disorders with undetermined etiologies. The aim of this study was to examine the underlying mechanisms which may account for GSHV. Another goal was to determine if there is commonality in the variables which predict GSHV in patients with disorders which lack a clear organic basis (fibromyalgia and temporomandibular joint dysfunction) and if these or other variables predict GSHV in patients who have a condition with an organic origin (rheumatoid arthritis).
Methods: 33 fibromyalgia patients, 29 rheumatoid arthritis patients, 26 temporomandibular joint dysfunction patients, and 34 healthy control subjects completed questionnaires which measured four variables which were hypothesized to predict GSHV: bodily monitoring, trait anxiety, symptom attributional style, and coping response.
Results: Data were analyzed using multiple regression analyses. The results indicated that trait anxiety was the best predictor of GSHV for fibromyalgia patients whereas monitoring of bodily sensations and making psychological attributions for bodily sensations were the best predictors for the rheumatoid arthritis group. For the temporomandibular joint dysfunction group, bodily monitoring was found to be the best predictor variable.
Conclusions: Interestingly, different variables were found to predict GSHV for the various chronic pain groups. Contrary to our predictions, similar variables did not predict GSHV in the fibromyalgia and the temporomandibular joint dysfunction patients. The clinical and treatment implications of these findings are discussed.
Acknowledgment: Supported in part by a MRC Student Fellowship to the first author and a NSERC research grant to the second.
FEATURES OF SOMATISATION PREDICT ONSET OF CHRONIC WIDESPREAD PAIN: RESULTS FROM A LARGE POPULATION STUDY.
McBeth J, Macfarlane GJ, Benjamin S', Papageorgiou AC, Hunt IM, Silman AJ. Arthritis Research Campaign Epidemiology Unit and 'Dept of Psychiatry, Univ of Manchester Medical School, Manchester, Ml 3 9PT
Aim of Investigation: Chronic widespread pain (CWP), the clinical hallmark of the fibromyalgia syndrome, is associated with other physical and psychological symptoms both in the clinic and the community. We report the results from the first population based prospective study to examine the hypothesis that psychological and physical indicators ofsomatisation predict the development of new onsets of CWP.
Methods: 1953 adults aged between 18 and 69 years were recruited from a population sampling frame. At baseline, subjects completed a detailed pain questionnaire, which included a pain drawing. They also completed the following psycho-social instruments:
General Health Questionnaire (GHQ), Somatic Symptom Checklist (SCL), Fatigue Questionnaire, the Illness Attitude Scales (IAS) and the Self Care Assessment Schedule (SCAS). Individuals were followed up at 12 months and 1629 (89% of subjects still living at their baseline address) provided data on pain status using the same instruments.
Results: At baseline 825 subjects were totally pain free and 833 had musculoskeletal pain not satisfying criteria for CWP. Of these 18 (2%) and 63 (8%) respectively were classified as having CWP at follow up. After adjustment for age and sex there were strong relationships between baseline test scores and subsequent risk of CWP: GHQ (>6) Odds Ratio (OR) = 1.9, SCL (>2) OR = 4.4, fatigue (>1) OR = 2.2, the Illness Behaviour sub-scale of the IAS (>7) OR = 5.9, SCAS (>4) OR = 2.2. All 95% Confidence Intervals excluded unity.
Conclusion: Subjects free of CWP are at increased future risk of development of this syndrome if they display other aspects ofsomatisation. Data from this population based prospective study lend powerful support to the hypothesis that CWP is one manifestation ofsomatisation.
Acknowledgments: Supported by a grant from the Arthritis Research Campaign S0542.
EVIDENCE FOR INVOLVEMENT OF 5-HT2A AND 5-HT2C RECEPTOR GENES IN FIBROMYALGIA
M. Offenbaecher'. B. Bondy2, S. de Jonge2, K. Glatzeder', S. Be-hrens2, P. Schoeps', M. Ackenheil2 (SPON: P. Kroeling). 'Dept of Physical Medicine and Rehabilitation and Dept of Psychiatry, Univ Hospital, 80336 Munich, Germany
Objective: To investigate several parameters of the serotonin (5-HT) pathway [genes of 5-HT2A and 5-HT2C receptors as well as tryptophan-hydroxylase(TPH)] in fibromyalgia (FM) and to correlate these findings with psychopathological data of the patients.
Methods: 65 FM patients meeting the 1990 ACR criteria and 115 healthy controls took part in this study after informed consent. Ge-nomic DNA were genotyped for the biallelic polymorphism of the TPH gene A-to-C conversion (U and L allels) and polymorphisms of the 5-HT2A (T102C) and 5-HT2C (C32S) receptor-genes. Additionally we administered the Symptom Check List 90-R to the FM patients.
Results: In our patient sample we did not find statistically different frequencies of the allels of the TPH gene as compared to controls (U: 0,38 vs. 0,42; L: 0,62 vs. 0,58). A similar nonsignificant result was obtained with the 5-HT2C (C32S) receptor gene allele. For the polymorphisms of both genes a tendency toward an increase of the mutant allele was observed. Concerning the 5-HT2A receptor, a different distribution was observed in FM patients with a decrease in homozygotes for the wild type (T allele: 11% vs. 24%) compensated for with an increase in heterozygotes (61% vs. 43%, p=0,04).
Conclusion: We found a statistically significant different distribution of the 5-HT2A (T102C) receptor-gene alleles in our fibromyalgia patients compared to healthy controls (p<0.05). The presence of the 5-HT2C (C32S) mutant was significantly correlated with the subscales 'Interpersonal Sensitivity'and 'Hostility' of the SCL-90 R (p=0,04). This results might point to a disturbance on 5-HT-receptor level at least in a subgroup ofFM patients and emphasizes the importance of the serotonergic system in the pathophysiology ofFM.
Acknowledgment: No grant or research support. No other form of financial interest or support.
MUSIC AND RELAXATION IN PATIENTS WITH FIBROMYALGIC PAIN.
Friedrich Paulak*. Wolfgang Pipam*, Franz Wendtner*, Patrick Bematzky*, Rudolf Likar and Guenther Bematzky. Herbert von Karajan Centrum Vienna, Salzburg Univ and General Hospital Klagenfurt, St. Veiterstr. 47, 9020 Klagenfurt, Austria
Aim of Investigation: Is it possible to obtain a pain-relieving effect with music and/or relaxation texts in patients suffering from fibro-myalgic pain?
Methods: 40 patients of both sexes suffering from fibromyalgic pain were assigned to four different groups in accordance to the time they were admitted: group 1 (music and relaxation instructions), group 2 (music only), group 3 (relaxation instructions only), group 4 (no intervention). To undergo the intervention therapy methods, patients had to wear headphones in each often therapy sessions (30 min. each). Before and after each relaxation session, the effects were evaluated by using the following instruments: pain evaluation: VAS; measurement of the following body parameters with biofeedback: skin conductivity value, heart rate, pulse volume amplitude, temperature, and EMG oftrapezius; questionnaires at the beginning and the end of the study: questionnaire about subjective state of health (according to Zerssen, 1975), general depression scale, pain sensation scale, questionnaire for acquiring data on how a patient copes with pain, questionnaire on function, Hannover polyarthritis and back pain.
Results: In the course of the sessions, patients suffering from fibromyalgic pain experience a differently intense pain-relieving effect, depending on the intervention method: group 1: strong pain-relieving effect; group 2: slight pain-relieving effect; group 3: enhanced pain-relieving effect; group 4: weakest pain-relieving effect.
Conclusion: The results of this study demonstrate that music and the combination of music and relaxation instructions, respectively, yield a substantial pain-reducing effect and thus substantially enhance the patients ability to cope with the respective illness.
Acknowledgments: Financial support was granted by the Herbert von Karajan Centrum Vienna and by Insight Instruments Company (Vienna).
PRESSURE PAIN THRESHOLDS AND MUSCULAR FATIGUE AFTER STATIC WORKLOAD IN CHRONIC SHOULDER PAIN
Ann Persson. Gert-Ake Hansson, Jarkko Kalliomaki, Ulrich Moritz, Bengt Sjolund, Depts of Rehabilitation and Occupational & Environmental Medicine, Lund Univ Hospital, 22185 Lund, Sweden
Aim of Investigation: We have previously found a bilateral, lasting increase of pressure pain thresholds (PPT:s) after a unilateral endurance test in healthy women. The duration was far beyond that of EMG-related muscular fatigue, indicating that intrinsic muscular processes did not influence the nociceptors. We have now sub-jected women with chronic muscle pain to the same paradigm to evaluate whether their PPT pattern could contribute to an understanding of their pain.
Methods: 17 women (mean age 47 yrs) with unilateral shoulder muscle pain since one year were subjected to a submaximal unilat-: eral activation of the shoulder muscles on the painful side. The maximal endurance time was measured and the PPT:s were registered with an electronic algometer on seven defined points bilaterally over the trapezius and the deltoid muscles before, immediately after, 10 min after and 20 min after the end of the test. EMG was recorded continuously over the same muscles and later analyzed for signs of fatigue and recovery (trapezius: root mean square /RMS/ increase; deltoid: mean power frequency /MPF/ decrease).
Results: The average endurance time recorded was 195 (range 90-390) s, compared to 330 (range 220-616) s in the healthy group. There were little changes in PPT thresholds after the present endurance tests, in spite of that the pretest absolute PPT values were similar to those in normals. The muscular fatigue signs were significantly less pronounced among the present pain patients (trapezius RMS 130 vs 188% and deltoid MPF 83 vs 72%) as compared to the healthy group.
Conclusions: The bilateral PPT increase previously demonstrated after a unilateral endurance test was not seen in the present patients with chronic shoulder pain, indicating a difference in sensory processing as compared to normal conditions.
Acknowledgment: Grants from the National Trust of Traffic Victims, from the Sw. Council for Work Life Research, the Sw. National Institue for Working Life and the Sw. Medical Research Council.
HYPERVIGILANCE FOR INNOCIOUS ELECTRICAL STIMULI IN FIBROMYALGIA.
Madelon Peters. Johan Vlaeyen, Dept of Medical, Clinical and Experimental Psychology, Univ of Maastricht, 6200 MD Maastricht, NL
Aim of Investigation: To investigate whether fibromyalgia patients display generalized hyper-vigilance for somatosensory signals.
Methods: 30 Fibromyalgic and 30 controls subjects participated in a visual reaction time (RT) task and a task measuring detection latency (DL) of weak electrical stimuli. Electrical stimuli gradually increasing in strength (0 to 1mA in 30 sec) were given to one of four positions (right/left arms and legs) and time to detection of the correct position was measured. Visual RT and stimulus detection tasks were performed under single and dual task conditions. Fi-bromyalgics were expected to have shorter DL for electrical stimuli both in the single and dual task. Moreover, under dual task conditions, less increase in stimulus DL and more increase in visual RT was predicted for fibromyalgics due to preferential attention allocation to somato-sensory stimuli.
Results: There were no significant differences between fibromyalgics and controls in DL either in the single or dual task. As expected, both RT and DL were significantly longer under dual than under single task conditions, but the two groups did not differ in the degree of slowing down on either parameter. The only significant finding was that within the fibromyalgia group, DL for stimuli on the arm, but not on the leg, were predicted by pain-related fear as measured by the Pain Anxiety Symptoms Scale (PASS). Conclusions: No evidence was found for generalized hypervigi-lance in fibromyalgia patients. In comparison to controls, patients did not show superior detection for weak electrical signals, neither under single nor dual task conditions. However, patients reporting more pain-related fear did seem to have an increased capacity to detect weak signals. These results suggest that hypervigilance is more associated with pain-related fear than with fibromyalgia in general.
PAIN AND PAIN RELIEF IN FIBROMYALGIA. A PROSPECTIVE TWO-YEAR LONGITUDINAL STUDY
R. Poyhia. MD, PhD, M.-A. Fitzcharles*, MB, ChB, FRCP (C), McGill-MGH Pain Centre, Division of Rheumatology, McGill Univ, 1650 Cedar Ave, Montreal, QC, H3G 1A4, CA
Aim of Investigation. To investigate the natural history of fibromyalgia (FM) and to examine the use of medications in FM.
Methods. 82 women (>18 yrs of age) with a primary clinical diagnosis of FM (widespread pain, presence of 11 of 18 tender points) were enrolled in this prospective longitudinal study in 1995. The patients were referred for the study and remained to be followed by primary care physicians or rheumatologists. No specific directions as to management were given by the investigators. A detailed clinical examination was performed, and the intensity of pain and other symptoms was assessed using a VAS upon entry to the study, 1 and 2 yrs later. Functional ability was measured using the Health Assessment Questionnaire (HAQ) and the Fibromyalgia Impact Questionnaire (FIQ).
Results. Out of all patients 82% were examined after the 1 st year and 79% after the 2nd year. Mean VASpam-values decreased from 67 to 53, the mean occurence of widespread pain from 99% to 52% and the mean number offender points/patient from 13 to 9 (p<0.001). Most patients improved their functions. Only few patients reported benefit from their medications. The use of prescribed medications decreased but the use of alternative medication increased.
Conclusions. The natural outcome ofFM is favorable. However, meaningful outcome measures and more effective medications need to be developed.
CLINICAL AND MMG CHARACTERISTICS OF MYOFASCIAL PAIN OF CALF MUSCLES IN PATIENTS WITH SCIATICA.
AR Shacurov*, RZ Moukhamedzianov. RA Altunbaev*, SV Ka-zarov*, MU Khabibullin*, E.I. Bogdanov*, Kazan Med. Univ., Dept. ofNeurol. & Rehab., Butlerova str.49, Kazan 420012, Russia.
Aim of Investigation: The influence ofpostisometric relaxation (PIR) (D. Simons, K. Lewitt, 1981) on the contractile properties of the calf muscles in patients with sciatica, and myofascial trigger points (MTP).
Materials and Methods: 84 patients age 22-67 with the sciatica, and radicular disturbances were clinically, isometric mechanomyo-graphically (MMG) tested before and immediately after PIR. The control included contralateral leg in non affected muscles. MMG performed according to March E., et al. 1981; Bogdanov E.I. et al. 1987,1991.
Results: MTP were revealed in patients with S,, radiculopathy at biceps femoris muscle, soleus, medial and lateral heads ofgastroc-nemius, piriformis; L5 radiculopathy tibialis anterior (TA), pirifor-mis, biceps femoris, soleus; L^ radiculopathy - TA, medial and lateral heads of gastrocnemius, piriformis. After PIR ofTA, medial head of gastrocnemius and soleus muscles the increase ofPt (maximum twitch force) and contraction and half relaxation time (CT and 1/2RT) more prominent in the disturbed leg was revealed.
Conclusion: Clinical features and distribution of MTP depend upon different myotoms (Trage, 1965). The development of MTP in the leg muscles of patients with sciatica wasn't absolutely similar to those described by D. Simons & J. Travell (1983). On the one hand the PIR treatment has an antimyalgyc effect and increases Pt and contraction and relaxation time in the disturbed leg, but on the other this effect is typical for denervation process which more severe manifested after PIR. The effects of PIR, probably, influence the contractile and activating system of muscles.
KAPPA (?) AND MU (?) BUT NOT DELTA (?) OPI-OID RECEPTORS ARE DOWN-REGULATED IN PATIENTS WITH FIBROMYALGIA.
Haiko Sprott* , Janine Rethage' ', Michel Neidhart' ', Renate E. Gay ' Uwe Wollina'2, Laurence A. Bradley 3, Graciela S. Alar-con" 3, Shin J. Oh' ", Steffen Gay' ' 'Center Exp Rheumatol, Dept Rheumatol, Univ Hosp Zurich, CH-8091 Zurich, Switzerland;
^Dept Dermatol, FS Univ Jena, D-07740 Jena, Germany, 'Dept Medicine and ''Dept Neurol, Univ Alabama Birmingham, Birmingham, AL 35294
Aim of Investigation: To determine whether peripheral opioid receptors are involved in pain modulation and transmission in skin and muscle tissue of patients with fibromyalgia (FM). Methods: Snap frozen skin tissues from 45 FM patients (mean age [± SEM] 46.6 [± 2.5] years, mean duration of symptoms 4.8 [± 1.1] years) as well as muscle tissue specimens from 10 FM patients (mean age 45.0 [± 4.4] years, mean duration of symptoms 15.1 [± 4.6] years) were examined by RT-PCR to detect specific mRNA for the 5, k, and u opioid receptors, and compared to 22 skin and 10 muscle tissue specimens from age- and gender-matched healthy controls. The Mann Whitney U-test was performed for statistical analysis.
Results: 6.7% ofFM skin tissue samples and 26.1% of control skin specimens showed positive bands for the k receptor in RT-PCR (p = 0.026). Mu receptor was positive in 42.2% ofFM patients and in 86.9% of controls (p < 0.001). No significant differences could be detected for the expression of 6 opioid receptor (93.3% in FM vs. 91.3% in controls). Moreover, no differences could be observed between the muscle tissues.
Conclusions: We observed a significant lower occurence of the k and u opioid receptors in the skin of patients with FM compared to healthy controls. These results suggest that down-regulation of peripheral opioid receptors may prevent endogenous opioid-mediated analgesia in patients with FM and thereby contribute to the perception of chronic pain. The 5 opioid receptor appears to be a target for future therapeutic interventions due to ist unaltered expression.
Acknowledgments: Dr. Sprott was supported by the DAAD and the DFG, all others by their respective institutions as cited above.
THE EVOKED BRAIN POTENTIALS WHILE THE MYOFASCIAL PAIN SYNDROME.
Staroseltseva N., Ivanichev G., Post Box 12, 420012 Kazan, Russia
The Subject of the Investigation: The examination of the evoked brain potentials while the chronic myofascial pain syndrome before and after myofascial puncture trigger points.
Methods: longloop reflexes (spinal-bulbo-spinal), brainstem acoustic evoked potentials (BAEP).
Results: 87 patients with myofascial pain syndrome had been clinically examined. Those 87patients and 40 healthy volunteers underwent the neurophysiological tests. No feasible distinctions between the neurophysiogical criteria (latency) of long loop reflexes of both the patients and the healthy volunteers had been found. The two tendencies of the latency mutation in comparison with the staring position (increase and decrease) were observed while the analgesic myofascial puncture. The latency increase was accompanied with the increase of the 3rd and the 4th BAEP peaks. The latency decrease was observed while the decrease of the 2nd and the increase of the 5th BAEP peaks. In order to avoid the influence of the needle puncture on the results of the research the 11 BAEP with each individual had been held under three various conditions: 1) The starting condition; 2) The myopuncture of the painless muscle area with the trigger point; 3) myofascial puncture of the trigger point.
Conclusions: The analgesic effect of the myofascial puncture correlated with the variations of the refectory and the acoustic systems. The absence of the feasible latency variation of the long loop reflexes in both investigation groups showed the failure of the tension antinociceptic system. The statistic observation of the three BAEP conditions has made it clear that that the amplitude criteria can be divided into three groups.
UPPER QUARTER MYOFASCIAL PAIN SYNDROME IN SINGAPORE: CHARACTERISTICS AND TREATMENT.
Alan Tay*, Kay-Fei Chan, Karen Chua*. Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore, S 569766.
Aim of Investigation: To study regional muscle distribution, pain intensity and treatment outcome in upper quarter myofascial pain syndrome (UQMPS).
Methods: Patients with chronic UQMPS were referred to an occupational therapist of a multidisciplinary pain clinic over a 2-year period. Hand dominance, regional muscle groups affected, pre- and post- treatment pain intensity by Visual Analogue Scale (VAS) were documented. Active myofascial trigger points were identified systematically and pain interventions included ischaemic compression techniques, passive stretching and physical modalities.
Results: Altogether, there were 32 patients (25 females, 7 males) with a mean age of 42.5 +/- 12.1 years. Mean pain duration was 2.9 +/- 2.1 years and bilaterality of symptoms was present in 65.5%. The mean number of muscle groups affected per patient was 5.9 +/- 3.3. The non-dominant upper limb was affected in 25%. 93.8% and 62.5% had active trigger points located in the trapezius and scalenes respectively. Other affected muscles included the rhomboids (59.4%), spinatii (53. 1%), and stemocleidomastoids (18.8%). Mean pre-treatment VAS scores were 7.9 +/- 1.2. The median treatment period was 5 weeks, with weekly treatment sessions and response rates of 100%. Post-treatment VAS scores were significantly reduced to 3.8 +/- 1.5 (p < 0. 001). 5 patients required maintenance pain medications.
Conclusions: UOMPS may result in chronic, severe pain frequently involving the trapezius. Physical therapeutic interventions can result in significant pain relief.
PRELIMINARY EXPERIENCE WITH TRIGGER POINT DEACTIVATION USING ACUPUNCTURE NEEDLES IN MYOFASCIAL PAIN.
Adela Tow. Kay-Fei Chan, Dept of Rehabilitation Medicine, Tan Tock Seng Hospital, Republic of Singapore
Aim: To document the intial experience with the use of acupuncture (AP) needles in trigger point (TP) deactivation. This differs from conventional TP needling in that AP needles are much finer, do not have a bevelled tip and TPs can be deactivated by leaving the needles without manipulation.
Methodology and Results: Out of 12 patients consecutively treated in the pain clinic setting over 6 months, 5 presented with pain in the upper and 7 in the lower quadrant. Duration of pain ranged from 2 months to 30 years. Visual analogue scale was 7 to 10 pre-treatment and 0 to 6 post-treatment, average of 8 and 3.8 respectively. Ninety-two percent reported pain relief within one week with one patient reporting total pain relief lasting at least 5 weeks. All patients reported post-injection soreness lasting 1-2 days. Pain levels did not improve in 4 patients. Of these, one patient had ongoing mechanical factors which was not easily corrected, another defaulted therapy, and the remaining 2 had ongoing job stressors.
Conclusions: We conclude that the above method of treatment is effective for the treatment ofMF pain, provided concomitant precipitating factors are eliminated, and the exercise program adhered to. Further studies may be needed to compare its efficacy with conventional TP deactivation with needling and infiltration.
FAMILIAL AGGREGATION OF LOW PAIN THRESHOLD AND WIDESPREAD PAIN
Weir. R.. Crook, J., Tunks, E., Khostanteen, R., McMaster Univ, Hamilton, Ontario, L8N 3Z5, Canada
Aim of Investigation: To determine if the traits of pain tenderness and widespread pain are distributed within the normal population and aggregate along familial lines.
Methods: A case control design was used. Family members of cases with fibromyalgia and family members of controls without fibromyalgia were compared on pressure points established with a pressure dolorimeter and the presence of widespread pain. Additionally, subjects and their families were compared on the presence of co-morbid symptoms including depression, sleep disturbance, fatigue and pain related conditions.
Results: Nineteen matched cases and controls each provided at least two family members who completed all measures. (N-71 cases, N=63 controls). Females represented approximately 80% in each of the family groups. The results show a strong association (ICC=0.6) within family members and indicates a measure of "familial correlation".
Conclusions: The traits of tenderness and widespread pain distributed within the normal population permits a conceptualization of fibromyalgia, not as a disease, but as an extreme within a range of non-pathological traits which can be managed differently, e.g., with preventative approaches aimed at factors that exacerbate the traits. These traits are aggregated along familial groupings, therefore, people at risk for these benign but troublesome symptoms can be identified and problems dealt with prospectively by targeting "at risk" individuals.
HOSPITAL-BASED FUNCTIONAL STATUS NORMS FOR DRUG-FREE FEMALES DIAGNOSED WITH FIBROMYALGIA: A DESCRIPTIVE COMPARISION WITH OTHER CHRONIC ILLNESSES.
David A. Williams, Daniel J. Clauw, and Lara J. Glazer*, Depts of Rheumatology and Psychiatry, Georgetown Univ Medical Center, Washington DC, 20007, USA
Aim of the Investigation: The SF-36 is a widely used measure of functional status for which norms are available for healthy subjects and many medical illnesses. The current study sought to (1) identify norms on this functional status measure for fibromyalgia (FM) and (2) compare the FM normative values with a mild medical condition (hypertention - HTN) and a severe medical condition (congestive heart failure - CHF).
Methods: Patients were referrals to a hospital-based Rheumatology Clinic. Each patient was diagnosed according to ACR criteria. Patients also completed the SF-36. To be included in the study patients needed to be female and medication-free for at least 2 weeks prior to assessment. Scale scores were calculated and compared to previously published norms for HTN and CHF.
Results: Subjects were 24 females with FM having a mean age of 40yrs (SD=10.6). Normative scale values revealed that females with FM possess physical, and general health ratings that are midway between HTN and CHF. Ratings of physical role functioning were more similar to CHF than HTN. In all other domains females with FM were functioning more poorly than either comparison group: including body pain, vitality, social functioning, emotional role functioning, and mental health.
Conclusions: This study provides needed normative data on fibromyalgia for the SF-36. W^ien patients with FM are compared to groups identified as either a mild or a severe medical condition, patients with FM score worse than a severe medical condition in 5/8 domains. This study highlights the severe functional limitations found in this diagnostic group. Acknowledgments: Supported in part by NIH grant MH54877.
HEAT PAIN SENSITIVITY IN PATIENTS WITH FIBROMYALGIA (FM): RELATIONSHIP TO PRESSURE STIMULI
J.M. Wolf4'. F. Petzke2, A. Khine2', D.J. Clauw2 and R.H. Gracely'. 'Clinical Measurement and Mechanisms Unit, PNMB, NIDCR, NIH, Bethesda, MD, 20892; ^ept of Medicine, Rheumatology, Georgetown Univ Medical Center, Washington D.C. 20007, USA.
Aim of Investigation: Increased sensitivity to painful heat stimuli is well described in Fibromyalgia. However, little is known about the inter- and intraindividual psychophysical relationship between thermal and pressure stimuli.
Methods: Heat stimuli were applied to the left forearm using a simple ascending (ASC-H: 1°C incr. from 37°C to tolerance) and a multiple random staircase design (MRS-H: 72 stimuli titrated to pain intensity (PI) box scale values of 0.5, 9.5, and 13.5). Both ascending (ASC-P: 0.45-kg increments up to 4.54 kg) and random (RAN-P: a set of 7 stimuli repeated twice and randomly presented) pressure stimuli were applied to the thumbnails. Slope and intercept for individual stimulus response curves were determined and stimulus intensities normalized to a box scale rating of 9.5 (moderate pain). 39 FM patients and 20 age and gender matched healthy controls (HC) were tested.
Results: Measures for heat pain showed increased sensitivity in FM versus HC (mean PI ASC-H: 4.13±.35 vs. 2.4±.35 [±SEM], p<002 and mean MRS temperature: 42.8^.45 vs. 44.3±.45°C, p<003). Normalized temperature causing moderate pain was also lower in FM than in HC (ASC-H(9.5): 43.9±.33 vs. 45.7^,65 °C, p<007 and MRS-H(9.5): 43.2±.3 vs 44.6±.55°C, p<,04). Both in FM and HC these temperatures were significantly lower for MRS-H than ASC-H (p<007 and p<002). Increased "expectancy" (PI in ASC>RAN) was only seen in 18 % ofFM and 24% ofHC (p=.59). For both groups there were significant correlations between ASC-H, MRS-H, ASC-P, RAN-P (HC: r=.59-.91, p<.005; FM: r=.38-.77, p<.02-.0001).
Conclusions: Heat and pressure pain sensitivity in FM show similar psychophysical characteristics. Patient's response patterns are at least as consistent as in HC.
MUSCULOSKELETAL PAIN AND HYPERALGE-SIA: HIV-POSITIVITY VERSUS FIBROMYALGIA AND CHRONIC FATIGUE SYNDROME.
Leonardo Vecchiet. Sabina lezzi*, Giannapia Affaitati*, Jacopo Vecchiet0*, Eligio Pizzigallo0*, Maria Adele Giamberardino;
Depts of Internal Medicine and of "Infectious Diseases, "G. D'Annunzio" Univ ofChieti, Italy
Aim of Investigation: HIV-positivity is frequently associated with musculoskeletal pain complaints. This study investigated for the presence of muscle hyperalgesia in HIV-positive subjects compared to normals and patients with documented diffuse muscle hypersensitivity [i.e., with fibromyalgia (FS) and chronic fatigue syndrome (CFS)]. The outcome of the sensory evaluation was correlated to the spontaneous painful symptoms.
Methods: 15 HIV-positive subjects (5 women and 10 men, aged 27-36 years) were examined. Their seropositivity had been discovered 6 months-13 years before; two had AIDS, all the others were in the pre-clinical phase. Fifty-three percent (but not the two with AIDS) had been complaining of diffuse and persistent musculoskeletal pain for 6 months-2 years. All subjects were submitted to muscle pain threshold measurement to mechanical stimulation (PPT, measured via algometry) at deltoid, trapezius and quadriceps level, bilaterally, and in the typical tender point sites (TePs) of fibromyalgia (FS), to calculate TPA (average pain threshold at all 18 TePs). The results were compared with those recorded in corresponding areas in 8 normals, 8 FS and 8 CFS patients of comparable age.
Results: Pressure pain thresholds at trapezius, deltoid and quadriceps level in all HIV subjects were lower than normal, but the difference was not statistically significant; they were significantly higher than in FS (p<0.01) and CFS patients (p<0.05). Thresholds in symptomatic and asymptomatic HIV subjects did not differ significantly. Only 4 of the 15 HIV subjects showed tenderness (PPT<4 Kg) in at least 11 out of 18 TePs (of these, only one also had spontaneous muscle pain). TPA in HIV was significantly higher than in FS (p<0.03) and CFS (p<0.05) but significantly lower than in normals (p<0.05). TPA in symptomatic and asymptomatic HIV subjects did not differ significantly.
Conclusions: In spite of a high prevalence of spontaneous muscle pain, HIV subjects did not present overt muscle hyperalgesia. There was no correlation between muscle pain threshold pattern and spontaneous symptoms. It is hypothesized that, unlike in FS and CFS, muscle pain in HIV-positivity is to a large extent of the type "deep parietal without hyperalgesia".
CYTOCHROME C OXIDASE DEFICIENT FIBERS AND RAGGED-RED FIBERS IN TRAPEZIUS MUSCLE BIOPSIES FROM WOMEN WITH HIGH WORK DEMAND.
Larsson B. Bjork J, Lindman R, Henriksson KG, Gerdle B, Dept of Occupational and Environmental Medicine and Pain and Rehabilitation Centre Univ Hospitals of Lund and Linkoping, Sweden.
Aim of Investigation: The pathogenesis of work-related myalgia is poorly understood. Cytochrome C oxidase deficient (COXdef) fibers and ragged red fibers (RR-fibers) have been associated with work-related myalgia. This study was performed to further elucidate the role of COXdef fibers and RR-fibers in work-related myalgia.
Methods: Open trapezius biopsies were obtained from 25 cleaners with work-related trapezius myalgia. Biopsies also were obtained from 23 cleaners and 21 teachers without trapezius myalgia. The main work-task of the cleaners was floor cleaning, meaning high work demand on the trapezius muscle. All participants were women. RR-fibers show subsarcolemmal accumulation or proliferation ofmitochondria in succinate dehydrogenase (SDH) and Gomori trichrome stainings. COXdef fibers stain blue in a double COX/SDH staining. A detailed pain history including VAS-scales was obtained.
Results: A statistically significant difference in abundance of RR-fibers between cleaners and teachers was found. No statistically significant difference in frequency of COXdef fibers between the groups was found. Neither was such a difference found in frequency of RR-fibers between cleaners. No correlation was found between pain history in cleaners with myalgia and frequency of RR-fibers. 73% of the RR-fibers were COXdef fibers. Preliminary data show that a majority of COXdef fibers also are RR-fibers.
Conclusions: RR-fibers may be correlated to high work demand but not to pain. The overlapping of COXdef fibers and RR-fibers together with the increased numbers of RR-fibers in cleaners might support the hypothesis that COXdef fibers represent the first step in a reaction to high work demand and RR-fibers a later stage of the same process.
Acknowledgments: Supported by Swedish Council for Work life Research 96-0885, 96-1386, Swedish Medical Research Council K99-27X-12696-02B and Sven Johansson found.
FIBROMYALGIA AND HEMISENSITIVE SYNDROMES
H. H .S. Kaziyama. M. J.Teixeira. T.Y.Lin. M.J. Teixeira, M. Okada, Pain Clinic, Division of Physical Medicine, Univ ofSao Paulo Medical School, Rua Conselheiro Brotero 1539, cj 12, Cep 01232-010, Sao Paulo - Brazil
Aim of Investigation: Evaluation of cutaneous sensory abnormalities in patients with fibromialgia.
Methods: 76 fibromyalgic patients (ACR-1990) underwent full clinical, physiatric, psychiatric and neurological evaluation. Patients presenting motor, deep sensory, major psychiatric, and labo-ratorial or image (brain or/and spinal CT or NMR) abnormalities were previously excluded. A pin was used for evaluation of the cutaneous sensibility. At least, in 2 occasions, coincidence of the findings were used for consistence of the abnormalities
. Results: In 38.2% of the cases, hemibody hypalgesia was observed. Pain complaints more intense in the affected side.
Conclusion: Neurological congenital or acquired sensory processing may be related with fibromyalgia syndromes.
SPATIAL SUMMATION AND DIFFUSE NOXIOUS INHIBITORY CONTROL (DNIC) IN NORMAL AND FIBROMYALGIC PATIENTS
Serge Marchand'. Pierre Arsenault'*, Jean-Mathieu Racicot'*, Caroline Pepin'*, Luc Jasmin''2, 'Univ. du Quebec en Abitibi-Temiscamingue, Georgetown Univ.
Aim of Investigation: Spatial summation has been suggested to contribute to the progressive activation of DNIC. In fibromyalgia, a deficit of DNIC has been pointed out for a possible explanation in the complex pain pattern in these patients. The goal of this study was to measure pain perception during nociceptive (cold or hot) immersion of different body surfaces, in normal subjects and fibromyalgic patients, to find if DNIC will be triggered in these two populations.
Methods: 25 normal subjects (7 males, 18 females) and 22 fibromyalgic patients (4 males, 18 females) participated in this 4-session conterbalanced protocol. The hand and arm were arbitrarily divided into 8 segments from the finger tips to the shoulder. During a session, the subjects rated perceived pain intensity and unpleasantness every 15 seconds while immersing a part of the hand and arm for two min. in hot or cold circulating water. After a 5 min. rest, the subjects proceeded to the next immersion until all eight areas had been stimulated. During one session the immersion progressed from the finger tips to the shoulder (1 to 8), and during the other session the reverse order was used (8 to 1).
Results: In the control group, for the increasing surface immersion session (1 to 8), no correlation between surface and pain perception were found (R=0.142, P=0.109). For the decreasing surface session (8 to 1), pain perception was positively correlated with the surface immersed (R=0,394, P=0.0001). In the fibromyalgic patients, no differences were found between the two sessions. A significant correlation was found between the surface and the perceived pain intensity reported for both sessions (PO.01).
Conclusion: These results suggest that pain perception is related to spatial summation until the stimulation reaches and exceeds a critical surface, at which point pain perception progressively decreases with surface augmentation, suggesting the activation of DNIC. In fibromyalgic patients no differences have been ffiiund between the two sessions reinforcing the possibility of a deficit of DNIC in these patients.
Acknowledgments: Supported by Quebec FCAR and FRSQ
PSYCHOLOGICAL ASPECTS OF CHRONIC PAIN PATIENTS WITH WORK RELATED MUSCULO-SKELETAL DISORDERS (WMSD)
R.J. Moura. M.I.S.T. Coutinho, G.B. Galvan, T.Y. Lin, B. Boguschwal, Division PM&R, Univ of Sao Paulo Medical School, R. Tiquatira, 146, Saiide, Cep 04137-110 Sao Paulo-SP, Brazil.
Aim of Investigation: The purpose of the present study is to evaluate personality characteristics and psychological aspects of patients with WMSD.
Methods: Twenty patients underwent a multidisciplinary educational and treatment pain program for patients with WMSD were evaluated (95% female, mean age 35.2 and mean duration of pain 31 months). The evaluation consisted in semi-structured interviews and Wartegg test (WZT). The data were quantitative and qualitatively analysed.
Results: 90% of the patients were insecure about their intelectual and cognitive potential, 95% felt necessity to attend to expectations of other people, 95% used to react with anxiety and emotional insecurity to relationships, 80% had difficulties to adapt to new circumstances, 100% had low self esteem, 100% couldn't deal well with their limits.
Conclusions: Some personality and psychological aspects were frequently found in these patients, which seemed to be associated with WMSD. The assessment of psychological aspects are necessary for adequate management of patients with WMST and planning rehabilitation programs, which should include psychological approach.
9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p. 545 - 551
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