Comparison of manual lymph drainage therapy and connective tissue massage in women with fibromyalgia: a randomized controlled trial

Ekici G; Bakar Y; Akbayrak T; Yuksel I

OBJECTIVE: This study analyzed and compared the effects of manual lymph drainage therapy (MLDT) and connective tissue massage (CTM) in women with primary fibromyalgia (PFM).

METHODS: The study design was a randomized controlled trial. Fifty women with PFM completed the study. The patients were divided randomly into 2 groups. Whereas 25 of them received MLDT, the other 25 underwent CTM. The treatment program was carried out 5 times a week for 3 weeks in each group. Pain was evaluated by a visual analogue scale and algometry. The Fibromyalgia Impact Questionnaire (FIQ) and Nottingham Health Profile were used to describe health status and health-related quality of life (HRQoL). Wilcoxon signed rank test and Mann-Whitney U test were used to analyze the data.

RESULTS: In both groups, significant improvements were found regarding pain intensity, pain pressure threshold, and HRQoL (P < .05). However, the scores of FIQ-7 (P = .006), FIQ-9 (P = .006), and FIQ-total (P = .010) were significantly lower in the MLDT group than they were in the CTM group at the end of treatment.

CONCLUSIONS: For this particular group of patients, both MLDT and CTM appear to yield improvements in terms of pain, health status, and HRQoL. The results indicate that these manual therapy techniques might be used in the treatment of PFM. However, MLDT was found to be more effective than CTM according to some subitems of FIQ (morning tiredness and anxiety) and FIQ total score. Manual lymph drainage therapy might be preferred; however, further long-term follow-up studies are needed.

Journal of Manipulative & Physiological Therapeutics, 2009 Feb; 32(2): 127-33- abstract

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Illness behavior in patients on long-term sick leave due to chronic musculoskeletal pain

Patricia Olaya-Contreras; Jorma Styf

Background and purpose Methods for identification of patients with illness behavior in orthopedic settings are still being debated. The purpose of this study was to test the association between illness behavior, depressed mood, pain intensity, self-rated disability, and clinical status in patients with chronic musculoskeletal pain (CMP).

Methods We examined 174 consecutive sick-listed patients (90 women). Musculoskeletal function was estimated by range of motion, muscle strength, and motor and sensory function. The degree of illness behavior was measured by Waddell signs (WS).

Results WS were observed in 47/174 (27%) of the patients, 16% of whom manifested excessive illness behaviour. In general, more patients with WS were depressed (OR = 4.4; 95% CI: 1.8-11) and experienced greater pain (OR = 2.9; CI: 1.1-7.7). No abnormal physical function could be observed in two-thirds of the patients. Other predictive factors for manifesting WS at the clinical examinations were longer sick leave and previous full sick leave (p < 0.05).

Interpretation Excessive illness behavior is related to psychological distress in patients with CMP and long-term disability. Thus, some patients may also require psychological assessment. Looking for WS during consultation is useful for targeting other factors that may be important in the diagnostic process.

Acta Orthopaedica 2009; 80 (3): x–x  full text
DOI: 10.3109/17453670902988352
URL: http://dx.doi.org/10.3109/17453670902988352

A Novel Tool for the Assessment of Pain: Validation in Low Back Pain

Scholz J, Mannion RJ, Hord DE, Griffin RS, Rawal B, et al

Background

Adequate pain assessment is critical for evaluating the efficacy of analgesic treatment in clinical practice and during the development of new therapies. Yet the currently used scores of global pain intensity fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms. We have developed a tool for a standardized assessment of pain-related symptoms and signs that differentiates pain phenotypes independent of etiology.

Methods and Findings

Using a structured interview (16 questions) and a standardized bedside examination (23 tests), we prospectively assessed symptoms and signs in 130 patients with peripheral neuropathic pain caused by diabetic polyneuropathy, postherpetic neuralgia, or radicular low back pain (LBP), and in 57 patients with non-neuropathic (axial) LBP. A hierarchical cluster analysis revealed distinct association patterns of symptoms and signs (pain subtypes) that characterized six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain. Using a classification tree analysis, we identified the most discriminatory assessment items for the identification of pain subtypes. We combined these six interview questions and ten physical tests in a pain assessment tool that we named Standardized Evaluation of Pain (StEP). We validated StEP for the distinction between radicular and axial LBP in an independent group of 137 patients. StEP identified patients with radicular pain with high sensitivity (92%; 95% confidence interval [CI] 83%–97%) and specificity (97%; 95% CI 89%–100%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. In addition, we were able to reproduce subtypes of radicular and axial LBP, underscoring the utility of StEP for discerning distinct constellations of symptoms and signs.

Conclusions

We present a novel method of identifying pain subtypes that we believe reflect underlying pain mechanisms. We demonstrate that this new approach to pain assessment helps separate radicular from axial back pain. Beyond diagnostic utility, a standardized differentiation of pain subtypes that is independent of disease etiology may offer a unique opportunity to improve targeted analgesic treatment.

PLoS Medicine 6(4): e1000047.- full text

doi:10.1371/journal.pmed.1000047

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Baffling Chronic Pain Linked to Rewiring of Brain

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CHICAGO — Scientists peered at the brains of people with a baffling chronic pain condition and
discovered something surprising. Their brains looked like an inept cable guy had changed the
hookups, rewiring the areas related to emotion, pain perception and the temperature of their skin.

The new finding by scientists at Northwestern University’s Feinberg School of Medicine begins to
explain a mysterious condition that the medical community had doubted was real.

The people whose brains were examined have a chronic pain condition called complex region pain
syndrome (CRPS.) It’s a pernicious and nasty condition that usually begins with an injury causing
significant damage to the hand or the foot. For the majority of people, the pain from the injury
disappears once the limb is healed. But for 5 percent of the patients, the pain rages on long past
the healing, sometimes for the rest of people’s lives. About 200,00 people in the U.S. have this
condition.

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The Brain in Chronic CRPS Pain: Abnormal Gray-White Matter Interactions in Emotional and Autonomic Regions

PY. Geha, MN. Baliki, RN. Harden, WR. Bauer, TB. Parrish, AV. Apkarian

Chronic complex regional pain syndrome (CRPS) is a debilitating pain condition accompanied by autonomic abnormalities. We investigated gray matter morphometry and white matter anisotropy in CRPS patients and matched controls. Patients exhibited a disrupted relationship between white matter anisotropy and whole-brain gray matter volume; gray matter atrophy in a single cluster encompassing right insula, right ventromedial prefrontal cortex (VMPFC), and right nucleus accumbens; and a decrease in fractional anisotropy in the left cingulum-callosal bundle. Reorganization of white matter connectivity in these regions was characterized by branching pattern alterations, as well as increased (VMPFC to insula) and decreased (VMPFC to basal ganglion) connectivity. While regional atrophy differentially related to pain intensity and duration, the strength of connectivity between specific atrophied regions related to anxiety. These abnormalities encompass emotional, autonomic, and pain perception regions, implying that they likely play a critical role in the global clinical picture of CRPS.

Neuron, Volume 60, Issue 4, 26 November 2008, Pages 570-581(abstract only)

doi:10.1016/j.neuron.2008.08.022

Fibromyalgia: A Disorder of the Brain?

P Schweinhardt, KM. Sauro, MC Bushnell

This article presents evidence that fibromyalgia patients have alterations in CNS anatomy, physiology, and chemistry that potentially contribute to the symptoms experienced by these patients. There is substantial psychophysical evidence that fibromyalgia patients perceive pain and other noxious stimuli differently than healthy individuals and that normal pain modulatory systems, such as diffuse noxious inhibitory control mechanisms, are compromised in fibromyalgia. Furthermore, functional brain imaging studies revealing enhanced pain-related activations corroborate the patients’ reports of increased pain. Neurotransmitter studies show that fibromyalgia patients have abnormalities in dopaminergic, opioidergic, and serotoninergic systems. Finally, studies of brain anatomy show structural differences between the brains of fibromyalgia patients and healthy individuals. The cerebral alterations offer a compelling explanation for the multiple symptoms of fibromyalgia, including widespread pain and affective disturbances. The frequent comorbidity of fibromyalgia with stress-related disorders, such as chronic fatigue, posttraumatic stress disorder, irritable bowel syndrome, and depression, as well as the similarity of many CNS abnormalities, suggests at least a partial common substrate for these disorders. Despite the numerous cerebral alterations, fibromyalgia might not be a primary disorder of the brain but may be a consequence of early life stress or prolonged or severe stress, affecting brain modulatory circuitry of pain and emotions in genetically susceptible individuals

NEUROSCIENTIST 14(5):415—421, 2008 (abstract only)

DOI: 10.1177/1073858407312521

Chronic Back Pain Is Associated with Decreased Prefrontal and Thalamic Gray Matter Density

Apkarian AV, Sosa Y, Sonty S, Levy RM, Harden RN, Parrish TB, Gitelman DR.

The role of the brain in chronic pain conditions remains speculative. We compared brain morphology of 26 chronic back pain (CBP) patients to matched control subjects, using magnetic resonance imaging brain scan data and automated analysis techniques. CBP patients were divided into neuropathic, exhibiting pain because of sciatic nerve damage, and non-neuropathic groups. Pain-related characteristics were correlated to morphometric measures. Neocortical gray matter volume was compared after skull normalization. Patients with CBP showed 5-11% less neocortical gray matter volume than control subjects. The magnitude of this decrease is equivalent to the gray matter volume lost in 10-20 years of normal aging. The decreased volume was related to pain duration, indicating a 1.3 cm3 loss of gray matter for every year of chronic pain. Regional gray matter density in 17 CBP patients was compared with matched controls using voxel-based morphometry and nonparametric statistics. Gray matter density was reduced in bilateral dorsolateral prefrontal cortex and right thalamus and was strongly related to pain characteristics in a pattern distinct for neuropathic and non-neuropathic CBP. Our results imply that CBP is accompanied by brain atrophy and suggest that the pathophysiology of chronic pain includes thalamocortical processes.

The Journal of Neuroscience, November 17, 2004, 24(46):10410-10415;

Full text PDF

doi:10.1523/JNEUROSCI.2541-04.2004

Stress-induced Physiologic Changes as a Basis for the Biopsychosocial Model of Chronic Musculoskeletal Pain: A New Theory?

Finestone, Hillel M; Alfeeli, Aziz MBChB; Fisher, William A.

Objectives: (1) To integrate the scientific literatures of the biopsychosocial model of chronic musculoskeletal pain and of stress-induced physiologic wound and muscle changes, and (2) to propose a clinical assessment and treatment model that incorporates this dual literature into the management of chronic musculoskeletal pain.

Methods: English language literature search from January 1990 to February 2008 using the MEDLINE and PsycINFO databases and the keywords “wound healing,” “musculoskeletal injury,” “skeletal muscle injury,” “psychological,” “social,” “stress,” “anxiety,” and “pain.”

Results: An illustrative case report is introduced. Review of the scientific literature revealed that psychologic stress is associated with slower or delayed wound healing in stressed older adults, restrained mice, socially isolated hamsters, adults with leg wounds, and surgical patients. One study showed that expressive writing positively affected the healing of a small skin puncture. Psychosocial stress affected aspects of muscle activity and spinal loading. Slaughter studies demonstrated that high preslaughter stress in pigs negatively affected postslaughter meat quality. A clinical model for the treatment of selected patients with painful musculoskeletal symptoms is offered.

Discussion: Important links exist between psychologic and social factors and recovery from insults to the “soft tissues.” Identifiable biochemical and physiologic processes mediate this relationship. It is time to rethink and refine views of the role of psychologic and social factors in musculoskeletal illness, chronicity, and pain.

The Clinical Joiurnal of Pain, Volume 24(9), November/December 2008, pp 767-775 – abstract

Full text available in through MTABC member only website under the research tab and then library.

Fibromyalgia Can No Longer Be Called the “Invisible” Syndrome

Using single photon emission computed tomography (SPECT), researchers in France were able to detect functional abnormalities in certain regions in the brains of patients diagnosed with fibromyalgia, reinforcing the idea that symptoms of the disorder are related to a dysfunction in those parts of the brain where pain is processed.

Clinical Correlate of Brain SPECT Perfusion Abnormalities in Fibromyalgia

E Guedj, S Cammilleri, J Niboyet, P Dupont et al

The purpose of this study was to investigate the specific clinical correlate of brain SPECT perfusion abnormalities reported in fibromyalgia.

Methods:We performed a whole-brain voxel-based correlation analysis involving regional cerebral blood flow and various parameters related to pain (Visual Analog Scale, Tubingen Pain Behavior Scale, and Questionnaire Douleur de Saint-Antoine Scale), disability (Fibromyalgia Impact Questionnaire
[FIQ]), and anxiety and depression status (Hospital Anxiety and Depression scale) in 20 patients with fibromyalgia (P voxel, 0.005). Ten healthy control women were also included, in order to determine areas of significant hypo- and hyperperfusions in patients.

Results: FIQ total score was positively correlated with bilateral parietal perfusion, including postcentral cortex. These clusters of correlation were included in the areas of significant hyperperfusion. FIQ total score was also negatively correlated with perfusion of a left anterior temporal cluster, included in the areas of significant hypoperfusions. No other clinical correlation was observed with regional cerebral blood flow.

Conclusion: These results show that brain perfusion abnormalities in patients with fibromyalgia are correlated with the clinical severity of the disease.
The Journal of Nuclear Medicine 2008; 49:1798–1803

Ful text PDF
DOI: 10.2967/jnumed.108.053264