Fibromyalgia: Time for the rheumatologists to hand over?

The American College of Rheumatologists developed diagnostic criteria for fibromyalgia in 1990, the culmination of many years of debate and disparagement of the existence of this pain problem.  At the time, it was thought that it was a rheumatic complaint due to the presence of body pain and soft tissue tenderness, so the diagnosis and management of it was firmly in the rheumatologists camp.  Research over the last few years shows that it is in fact a pain syndrome centered in the nervous system. Two rheumatologists now suggest that fibromyalgia should no longer be managed by rheumatologists and it should be handed over to…primary care physicians.

The information above is drawn from an editorial by Shir and Fitzcharles, in The Journal of Rheumatology 2009; 36:4.  What does this startling suggestion mean really?

There are several points that this editorial makes:

  1. Fibromyalgia is no longer a diagnosis of exclusion, and diagnostic accuracy by GP’s has improved significantly (at least in the US)
  2. Exclusion of serious rheumatological or other disorders seems to be carried out quite effectively by GP’s
  3. Few investigations are needed to increase diagnostic accuracy
  4. ‘Successful management necessitates approaching the patient as a whole biopsychosocial being, with treatment strategies directed towards physical and psychological complaints within the context of family and society.’

I’m not going to argue with these points at all,  but I am going to suggest that leaving the management of fibromyalgia simply to the family physician might not be the best thing for the person with FM.  I don’t doubt the clinical skill of GP’s, and I think they are the best group to diagnose FM – but managing FM isn’t a single-clinician job.

While GP’s certainly know how to diagnose, and can prescribe the majority of medications used to manage fibromyalgia, my worry is that the rest of the management is not a medical task.  In fact it’s a biopsychosocial problem, as the 4th point above makes.  IMHO GP’s don’t have time or access to services in the community to help people with fibromyalgia to live well, it takes a team to do this.

If I had a wand, or the ear of a health funder, I’d be suggesting the formation of community-based teams of health providers consisting of occupational therapists, physiotherapists, psychologists, nurses and social workers.  I’d be asking them to work alongside GP’s, (perhaps even in the same buildings!) so that people being seen by the GP could then be included in a team approach to help them develop active coping strategies to live well, despite their health problems.

Now, as it happens, I don’t have the wand or ear, but I can hope.  As Shir and Fitzcharles state:

…the pathogenesis of FM is now firmly centered in the nervous system, and FM
is not a musculoskeletal complaint. Optimal patient management
requires attention to the many symptom components
of FM in addition to pain management. Patients with
FMwill also require prolonged care with continued tailoring
of treatments, as symptoms are likely to change over time.

Maybe one day soon my dream of community-based interdisciplinary teams to help people be well despite pain (or other chronic health problems) will be realised.  The sooner a biopsychosocial approach to managing these problems is adopted the better.

Information on fibromyalgia can be found here for a New Zealand site, here for a US site, here for another US site, and here for an Australian site.

If you’re a person with fibromyalgia, some caveats about anything on the internet:

FM has been a wonderful thing for people who sell so-called ‘cures’.  It’s such a diffuse problem, has been questioned for years by the medical community, is often not clearly diagnosed, and changes its presentation often – so people who are either unscrupulous, or are credulous can go about selling all sorts of potions, pills and gadgets for the ‘cure’ of the disorder.

FM doesn’t respond to very much, it’s a chronic central nervous system problem, and living with it means learning how to LIVE with it, not fight it, defeat it, or beat it.  It won’t just disappear of its own accord, and it won’t disappear because of some herbal, crystal, magnetic Thing.

Be sceptical, ask for evidence and don’t accept anecdote or endorsements as evidence for the power of any treatment.  Self management is really the only way to live well with FM, although some medications can help.  Here’s a good site for learning about self management for FM, and here’s a brief overview of a study about how self management can improve the outcomes of exercise in FM.

SHIR, Y., & FITZCHARLES, M. (2009). Should Rheumatologists Retain Ownership of Fibromyalgia? The Journal of Rheumatology, 36 (4), 667-670 DOI: 10.3899/jrheum.081073

Pacing and avoidance in fibromyalgia

The recent emergence of study into ‘pacing’ or activity regulation in pain management is a welcome addition to our knowledge of this coping strategy. Although pacing has been described and included in many self-help books as well as clinical texts as an effective strategy for people with chronic pain to use, the research base for its use is pretty skinny (see Gill and Brown, 2009). McCracken and Samuels (2007) found that increased use of pacing was associated with higher disability and less acceptance, while Nielson and Jensen (2004) found that it was associated with lower disability in people with fibromyalgia.

The study I’m looking at today, by Karsdorp and Vlaeyen, looked in whether pacing specifically was different from ‘other behavioural strategies assessed with the Chronic Pain Coping Inventory (CPCI), such as guarding, resting, asking for assistance, relaxation, task persistence, exercise/stretch, seeking social support, and coping self-statements.’ The second part of this study looks more closely at whether ‘pacing was associated with physical disability when controlling for pain catastrophizing, pain severity and the other behavioural strategies as measured with CPCI.’

The methodology was pretty simple: a random sample of around 400 patients from the Dutch Fibromyalgia Association responded to being sent a set of questionnaires, a response rate of 68%. 388 women; mean age = 47.58 years, SD = 10.18, range 18–75 years. The mean duration of pain was 160 months (SD = 116.79). Thirty-four percent of the patients had a job and 39% of the patients received income from a disability income insurance.

The questionnaires used were the Chronic Pain Coping Inventory (Jensen, Turner, Romano & Strom, 1995). CPCI comprises 70 items measuring 9 behavioural strategies: Guarding (9 items), Resting (7 items), Asking for Assistance (4 items) , Relaxation (7 items), Task Persistence (6 items), Exercise/Stretch (12 items), Seeking Social Support (8 items), Coping Self-statements (11 items), and Pacing (6 items).
Pain intensity was measured using VAS, catastrophising was measured using the Pain Catastrophising Questionnaire (Sullivan, Bishop & Pivik, 1995), functioning was measured using a fibromyalgia specific Fibromyalgia Impact Questionnaire (FIQ-PH) (Burckhardt, Clark & Bennett, 1991), and the Pain Disability Index (Pollard, 1984) were used. Note: these were translated into Dutch for this study.

Thank goodness for statistics! Multiple regression analysis was undertaken – two hierarchical regression analyses were conducted with physical functioning or disability as the dependent variables. The first step included gender, age, and education, pain intensity, and pain catastrophizing. At the second and third step, the 8 CPCI subscales and the pacing subscale were entered, respectively.

What did they find?
At step one in the regression analysis, the demographic variables, pain intensity, and pain catastrophizing explained a significant amount of variance in physical functioning.

Older patients, patients with more severe pain, and patients who tended to catastrophize about pain reported greater physical impairment and more disability.

At step two, the 8 CPCI subscales without the pacing scale reduced the effect of age and pain catastrophizing to zero and significantly explained an additional amount of variance in physical functioning.

At step 3, the pacing subscale did not explain a significant additional amount of variance in physical functioning, leaving, in the final model, patients who avoided physical activities and asked for assistance to manage their pain reported greater physical impairment and more disability, even when controlling for demographic variables, pain intensity, pain catastrophizing and the other behavioural strategies.

So, what does this mean?
Remember, the first question was whether pacing forms a separate scale within the Chronic Pain Coping Inventory, and it seems to – at least in this Dutch version of the CPCI. Pacing is different from guarding, asking for help, avoiding and so on.

The second question was whether pacing was associated with physical disability when controlling for pain catastrophizing, pain severity and the other behavioural strategies as measured with CPCI. The reason for testing this hypothesis was to ascertain whether ‘activity pacing is an adaptive behavioural strategy that could be taught in pain management programs to improve adjustment in FM.’

Zero-order correlations revealed that patients using more pacing strategies reported greater physical impairment and more disability as opposed to less physical disability, so perhaps not such a great strategy to use – but wait: regression analysis demonstrated that pacing did not significantly contribute to physical functioning and disability over and above demographic variables, pain severity, pain catastrophizing and other behavioural strategies reported in chronic pain.

This means that the present study suggests that helping patients to increase pacing strategies in pain management programs may not be a key element in diminishing disability in FM. The authors suggest that the context in which pacing is used may determine whether it’s adaptive or not. Some patients may use pacing as an avoidance strategy, while others may use it, along with graded activity, to increase their ability over time.

The two strongest predictors of disability in this study were guarding and asking for assistance, which are likely to be dysfunctional strategies in FM. This shouldn’t be surprising, as these findings fit with the fear-avoidance model of disability.

Now, some caveats when interpreting this study. Don’t ever confuse correlation with causation – this is a correlational study, so there could very well be some intermediate factor that moderates the effect of activity pacing and disability. The authors quite rightly identify this. Longitudinal and experimental designs are needed to explore the relationship between activity pacing and disability in much more detail. Observational studies are needed to counter the self-report nature of the study instruments in this study. (Of course, we know how difficult observational studies are to carry out!).

Nevertheless, the authors suggest (and I agree based on my experience) pain management programs targeting activity pacing or behavioural strategies in general may not be effective in FM. Instead, therapeutic interventions based on fear-avoidance models specifically targeting paradoxical safety behaviours are likely to be useful in FM. I’m not sure we do exposure therapy as well as we might – and I’m certainly not sure we identify safety behaviours well at all. Perhaps something to explore in the future?

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Karsdorp, P., & Vlaeyen, J. (2009). Active avoidance but not activity pacing is associated with disability in fibromyalgia Pain DOI: 10.1016/j.pain.2009.07.019

J.R. Gill and C.A.A. Brown, Structured review of the evidence for pacing as a chronic pain intervention, Eur J Pain 13 (2009), pp. 214–216.

L.M. McCracken and V.M. Samuel, The role of avoidance, pacing, and other activity patterns in chronic pain, Pain 130 (2007), pp. 119–125.

W.R. Nielson and M.P. Jensen, Relationship between changes in coping and treatment outcome in patients with Fibromyalgia Syndrome, Pain 109 (2004), pp. 233–241.

What is self management in chronic pain?

Self management. It’s term we use very often in pain management, but do we really agree about what we’re talking about?

Maybe self management is different things to different people, maybe even different things to different people at different times! But if we don’t talk about what we’re aiming for, especially if we’re in a team that don’t talk – we’re bound to run into trouble.

Self management has been defined by academics in several ways, which doesn’t help, but all the definitions seem to include concepts of wellbeing, activities that the person with the health condition does, and encounters with the health system. The Institute for Healthcare Improvement states that self management includes three things:

  • care of the body and management of the condition,
  • adapting everyday activities and roles to the condition, and
  • dealing with the emotions arising from having the condition

They also sayGood self-management support involves collaboration between patient and their care provider, one in which the provider is a coach as well as clinician and the patient and family are managers of daily care. ‘

One of the assumptions that I intially had about pain self management was that it was mainly nonmedical.  Visits to the GP for repeat presscriptions maybe, but nothing more.  I assumed that the pursuit of pain reduction would be mainly over, that living a life instead of being a patient would be the focus.  That is certainly my focus in my life with fibromyalgia.

Some of my colleagues believe that once a person has had exposure to pain management, especially group-based, intensive pain management, that should be enough and the patient be discharged to the GP.  Others think that a single programme, no matter how well-delivered, may not be all things to all people.

Some of my colleagues think that working individually with people is the best way to deliver pain self management – and that seeing a person once a week for, say, 12 weeks is the best way to ensure they’ve developed and integrated their coping strategies into life.  Some others think this isn’t enough intensity to create behavioural change and that there is something added by exposure to a group process.

I’m still pondering.  From what I’ve read in the literature, ‘pain management lite’, or individual sessions a couple of times a week for however many weeks doesn’t have as much impact as intensive ‘immersion’ pain management every day for three weeks.  But I know that a three week pain management programme alone doesn’t always have the long-lasting impact that I’d hope it could.

I’ve also read about self management in other health conditions – most of the literature in, for example, diabetes and respiratory conditions, shows that ‘fading’ or providing gradually decreasing support for self management while handing over from secondary care to primary care is more effective than simply providing ‘a programme’ and discharging into the community.

We don’t do this at the moment in pain management.

My thoughts

Here’s my current take on self management in chronic pain – this is my opinion, based on my experiences and reading of the self management literature.

  1. People are more or less ready for self management – the stages of change model seems to have some bearing on the degree of acceptance that people have for learning to live with their pain rather than seeking pain reduction.  This means that some people are ready for only certain aspects of self management, and that they may need several exposures at self management before they take control.
  2. Some people need the intensity of a full time, three week group programme to start to feel confident that self management applies to them, and to get the constant reinforcement of behaviour change.  Three weeks of hearing other people in the same position as themselves, often being challenged more strongly by group participants than the facilitators, and being supported daily to make behavioural changes is what they need to see that change is possible.  While a programme like this can’t always influence permanent changes, it can provide that initial impetus that less intensive approaches can’t do.
  3. Adopting self management involves a complex set of attitudes, beliefs and behaviours. It’s not like remembering to take medication on time, or doing daily exercise or even eating a more healthy diet.  It’s all of these AND attending to thinking patterns, setting goals, confronting the changed functional abilities, being satisfied with doing less or being challenged to do more, communicating effectively – all the while having messages from the media, family, community and even health care providers about finding ‘a quick fix’ in the form of medication, injections, surgery.
  4. People don’t make changes easily and support (of the right kind) can help them maintain newly developed behaviours. The information from diabetes self management, among others, shows that providing ongoing but less intense support after new skills have been introduced, helps to maintain behaviour change.  I don’t think it’s enough to be exposed to new strategies, start to make changes, then be discharged to primary care.  What seems to work in diabetes and other chronic health conditions is either intermittent, time-limited support for the person with pain, or really effective support from the primary care clinician.  In my experience, primary care clinicians don’t always feel confident to give the kind of support that is needed to maintain pain self management.  Maybe there is another option: give both, AND support to the primary care team.
  5. People who have the offer of more pain reduction (through injections for example) find it really difficult to maintain self management, especially through setbacks and flare-ups.
  6. People seek help for their pain, even after self management, for many reasons – but often it’s not the pain itself that is the primary problem.  It could be low mood, new stressors, someone suggesting that a new treatment might ‘take the pain away’.  Maybe for some people, intermittent ‘booster’ sessions would reduce the potential for them to re-enter the medical ‘cure or pain reduction’ merry-go-round.  This might be less expensive than the alternatives and help retain the person’s focus on living as a person rather than a patient.
  7. Maybe self management isn’t for everyone. Some people really can’t believe that science hasn’t produced a cure for everything.  Some people do have secondary gain from being ‘unwell’.  Some people have so many other areas of vulnerability that they don’t have the resources to maintain self management.  Can we accept this?  And is there a way to minimise the unnecessary use of health care resources, maintain human dignity and choice, while providing support to the person and their family?  Is this what a secondary or tertiary health care provider can do that a primary provider cannot?

What I think is important is to work as a team.  Even if the person doesn’t adopt self management, if they come back for more ‘something’, it shouldn’t be a single discipline that makes the decision about the next best step for management.  We’re all likely to see the world through our own biases (what? even me?!!), so at the very least it would be helpful to discuss why someone has returned for more help before making a decision.

And keeping an eye on The Bigger Picture seems a good idea – after all, maybe seeing someone once every three months for a talk about their wellbeing is cheaper than having them go to Emergency Department or being referred for another round of investigations, or even having repeated injections.

Curious about hypnosis?

This week’s series of posts will probably be a bit random – bits and pieces of trivia that I find scattered about the interweb!

Like today’s post, which links to a site I stumbled across by chance, a New Zealand hypnotherapy site!

What I like about this site is the use of scientific references rather than opinion or testimony, and the list of myths that I think most people who teach hypnosis, and probably most people who try hypnosis, have encountered!

Some of the pages are not working, sadly – I’ve emailed the author Mike Reeves-McMillan from Titirangi in Auckland, so hopefully they’ll come back up sooner rather than later.  As you know I don’t endorse any specific therapist (or therapy) nor any products, but I do think the information on this site is worth a look.

If you’re interested in hypnosis – and fibromyalgia – this article, just published in European Journal of Pain and written by Stuart Derbyshire, Matthew Whalley and David Oakley, describes an fMRI analysis of Fibromyalgial pain and its modulation by hypnotic and non-hypnotic suggestion.

Recent studies from a range of discplines have been looking at the neuropsychology of ‘central sensitisation disorders’ such as fibromyalgia, irritable bowel syndrome, dysmennorhea, chronic fatigue syndrome and others (see Yunus, 2008).  This study uses fMRI to examine the changes that occur with suggestions regarding the pain experience of fibromyalgia with and without hypnotic induction.

The basic design was quite simple: suggestions following a hypnotic induction and the same suggestions without a hypnotic induction were used during functional MRI imaging to increase and decrease the subjective experience of fibromyalgia pain.

What happened? Suggestion in both conditions resulted in changes in reported pain intensity – but patients reported more control and greater pain reduction when they had been hypnotised.

What happened in the brain? Activation of the midbrain, cerebellum, thalamus and midcingulate, primary and secondary sensory, inferior parietal, insual and prefrontal cortices correlated wth reported changes.  The changes were of greater magnititue when suggestions followed a hypnotic induction in certain specific areas in the brain.

What does this tell us? It seems that in people who can be hypnotised, suggestions that fibromyalgia pain can be reduced (using an image of a dial which could be turned up or down) worked better in people who had a hypnotic induction.  The second interesting finding was that this indicates direct involvement of a network of areas widely associated with the pain ‘neuromatrix’ in the pain experience of people with fibromyalgia.

The study numbers were small, and typical of most experimental work, the selection criteria was quite strict – but for people who want to use hypnosis as a therapeutic strategy it is encouraging to see areas of the brain respond to the induction and suggestion.  Perhaps this is a strategy that is somewhat under-used in pain management – although I would probably call the method they used ‘imagery’ because it’s easier to describe and less likely to be misinterpreted by patients.

Derbeyshire SWG. et al., Fibromyalgia pain and its modulation by hypnotic and non-hypnotic suggestion: An fMRI analysis.  European Journal of Pain (2008), doi: 10.1016/j.ejpain.2008.06.010

YUNUS, M. (2008). Central Sensitivity Syndromes: A New Paradigm and Group Nosology for Fibromyalgia and Overlapping Conditions, and the Related Issue of Disease versus Illness. Seminars in Arthritis and Rheumatism, 37(6), 339-352. DOI: 10.1016/j.semarthrit.2007.09.003
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Distress and wellbeing – two sides of the same coin?

Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?
Alexa Hubera, Anna Lisa Sumana, Giovanni Biasib, Giancarlo Carlia

This is an interesting article on the concepts of wellbeing and distress. Distress is often considered a key element in whether someone has ‘good quality of life’ (see my post from a day or so ago), but in this article, the relationship between psychological distress and well-being was explored, and the predictors of both in patients with chronic nonmalignant pain are identified.

Why would we be bothered about distress and how is it measured? Distress is not a particularly well-defined concept, but is often referred to in the same breath as ‘eustress’ and ‘distress’ (see this entry in Wikipedia for an exploration of several theories relevant to stress and coping). If its used in this way, it often refers to suffering (which is about negative judgements of a situation or event), and is distinct from depression. Using Loeser’s onion rings model of pain, it’s the emotional judgement of pain that negatively impact on the individual.

In this article, however, the authors refer to two traditions and the impact these traditions have on our ideas about wellbeing. To quote ‘[the] hedonic approach focuses on happiness, while the eudaimonic approach defines well-being in terms of the degree to which a person is fully functioning, which may or may not be accompanied by feeling good.’
This reminds me of the traditional WHO definition of health – which is not simply the absence of disease!

One of the reasons I was drawn to this study was the statement by the authors that ‘To date, few studies on well-being in patients suffering from chronic pain have been published’. (Of course I’d argue that experiencing chronic pain may be mandatory, but ‘suffering’ is optional!) This is precisely the point I’ve been trying to make for some time in that most of our knowledge about people experiencing chronic pain is drawn from people who are seeking treatment. People who live well despite having chronic pain are not studied often and hence we know relatively little about them.

So, getting down to the nuts and bolts of this study: 69 women recruited from a University Hospital Rheumatology centre. The majority of them met criteria for fibromyalgia, while the remainder had widespread pain, and many of them also experienced other conditions associated with central sensitisation syndrome (e.g. psoriasis, irritable bowel syndrome, headache, fatigue).
They all completed a raft of measures, but the ones I want to focus on are those assessing distress:
The Symptom Check List-90 (SCL-90) measures psychiatric symptoms and psychological distress and has been used often in this type of research.
The State–Trait Anxiety Inventory Form Y (STAI-Y) consists of two scales measuring state (STAT-Y1) and trait anxiety (STAT-Y2), respectively. It’s been used in many studies of anxiety in different patient and community groups.

The Multidimensional Affect and Pain Survey (MAPS)was used to measure pain-related emotional suffering and well-being. It consists of 101 descriptors within 30 clusters, grouped into three scales.
The Somatosensory Pain scale measures somatosensory pain sensations, and its results weren’t considered in this study.
The Emotional Pain scale (EP) measures pain-related emotional suffering within eight areas: Physical Illness, Depressed Mood, Self-Blame, Anger, Anxiety, Fear, Apathy, and Fatigue.
The Well-Being scale (WB) measures aspects of wellbeing in five clusters. The first two clusters—Mentally Engaged (e.g.,“interested”) and Physically Active (e.g., “vigorous”)— measure healthy activities and follow the eudaimonic tradition (which defines well-being in terms of functioning, not happiness).
The third and fourth clusters—Affiliative Feelings (e.g.,“sympathetic”) and Positive Affect (e.g., “happy”)—measure happy thoughts and really within the hedonic tradition. The fifth cluster, Treatable Illness, measures to what extent the patient believes that his/her illness is “curable” or “manageable” and represents a separate dimension of well-being.

(Just a comment – I’m not sure of the relationship between this measure and measures of acceptance such as those being studied by McCracken and others).
The other variables included in this study were ‘general epidemiological–anamnestic questionnaire, six measures of physical symptoms (tender point count, pain area, pain intensity, fatigue, stiffness, and physical disability).

Now for some statistics – not particularly challenging ones, so don’t panic!
Pearson correlation coefficients were used to assess the relationships between measures of well-being and psychological distress, applying Bonferroni adjusted α levels.

These showed only three physical symptoms—pain intensity (VAS), number of positive tender points, and physical disability (FIQ)— showed meaningful correlations with psychological distress and/or well-being.

A hierarchical multiple regression analysis was carried out to separately predict each of the six measures of well-being (WB-4 and each of the five WB clusters) and three measures of psychological distress (MAPS EP, STAI-Y2, and SCL-90 GSI).  ‘Predictors were entered in the following order in five steps: (a) age; (b) pain duration (i.e., time passed since the onset of pain symptoms); (c) pain intensity; (d) number of positive tender points; and (e) physical disability.‘ Just so you know, several of these were mathematically transformed to make the stats assumptions work (which may affect the rigour of the results), but at least they told you about it!

Ok, results.
Well, almost half the participants reached the cut-off score for trait anxiety, and many of them also reached the score for high distress.  They sound fairly like the people that get referred to Burwood Pain Management Centre.

In terms of psychological distress, higher age and more physical disability emerged as the two most important predictors of psychological distress, each making unique contributions.

‘Both Pearson correlations (and multiple regression demonstrated that wellbeing (as measured by WB-4) was significantly predicted from low physical disability alone, and was independent of age, pain duration, pain intensity, and tender point count.’

What does this actually mean?
The results really show that the relationship between psychological distress and pain-related symptoms, may be mediated by the patient’s limitations in the capacity to perform daily household chores (ie disability).

We know that disability is influenced by a whole range of factors including the responses of significant others – and the cognitive interpretation of the meaning of those limitations, such as the disparity between what the person believes is expected of them as compared with what they believe they are capable of.  It’s not simply about pain intensity.

Wellbeing, on the other hand, decreased with higher disability but, in contrast to psychological distress, was independent of age, pain intensity, and tender point count.

Now the finding that well-being was independent of pain intensity is an important result of this study.

Yesterday I quoted from Katz where it was assumed that if pain intensity alone was reduced, ‘quality of life’ would improve. I wouldn’t want to equate ‘quality of life’ with ‘wellbeing’ – but the dimensions are similar, and suggest that it’s simply not enough to reduce pain without simultaneously addressing other issues that are important to the individual.

As the authors state ‘Our findings suggest that, in patients with chronic musculoskeletal pain, well-being is related to aspects of physical disability that are not directly linked with pain. The results are in line with the literature demonstrating that the negative impact of chronic pain on physical functioning and work status is moderated by cognitive and psychosocial factors, such as pain catastrophizing and pain-related fear of movement.’

They add ‘Results are consistent with the view that pain behavior, rather than pain per se, should be the target of treatment’. Not news to many of us, but perhaps to those clinicians with a somewhat simplistic (or perhaps simply a biomedical) viewpoint, it may be surprising.

I’m also keen to support their contention that psychological wellbeing should be measured as an outcome quite distinct from a reduction in psychological distress. It’s a new concept for health care – to think that along with ways to reduce distress, clinicians could also consider ways to enhance wellbeing – and that this can occur in the absence of a focus on pain reduction.

It makes me think that the emerging field of positive psychology is something that pain management clinicians could well start to view more seriously. My post from the other day on counting blessings comes to mind. And for those of us working in the field for the long term – it might make our work just a little lighter and more fun!

HUBER, A., SUMAN, A., BIASI, G., CARLI, G. (2008). Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?. Journal of Psychosomatic Research, 64(2), 169-175. DOI: 10.1016/j.jpsychores.2007.09.005

I’m really just a sensitive wee soul…

Fibromyalgia has been researched extensively over the past 5 – 10 years. I remember when it was a diagnosis of ‘last resort’ and almost became a condition to ‘dump’ patients who had widespread pain but few signs. It didn’t seem to make much difference to treatment either!

Now it looks like there is an ever-increasing range of studies showing the role of central sensitisation in the disorder. And as someone who meets criteria for fibromyalgia, I was interested to read this post by ‘ByTheBay’ where the results from a study by Geisser, Glass, Rajcevska, Clauw, Williams, Kileny & Gracely are discussed.

The hypothesis being tested was that “subjects with FM would display greater sensitivity to both pressure and auditory tones and report greater sensitivity to sounds encountered in daily activities.”

A group of 30 participants diagnosed with fibromyalgia and a group of 28 controls were identified, and were administered auditory tones and pressure using the same psychophysical methods to deliver the stimuli and a common way of scaling responses. Subjects were also administered a self-report questionnaire regarding sensitivity to everyday sounds. The findings?

Subjects with FM displayed greater sensitivity to pressure stimulation to the thumb compared with healthy control subjects for low-, medium-, and high-pressure intensities. The mean pressure needed to evoke these sensations for FM subjects were significantly lower than for healthy control subjects. As with pressure stimulation, significantly lower auditory stimulation was needed to evoke ratings of low, medium, and high pain intensity in FM subjects compared with healthy control subjects. In addition, subjects with FM reported having significantly greater hearing sensitivity on the hyperacusis questionnaire compared with healthy control subjects.

Consistent with prior research, subjects with FM demonstrated greater sensitivity to auditory tones compared with healthy control subjects. They also reported significantly greater sensitivity to daily sounds. Within both the patient and control groups, sound and pressure sensitivity measures were related to each other, suggesting a common underlying mechanism associated with these phenomena. Thus, these data lend further credence to the notion that FM is in part due to a global disturbance in sensory processing rather than an isolated abnormality in pain processing.

There are some limitations to this study: one is the cross-sectional design – it’s not apparent whether increased sensitivity occurs as a result of fibromyalgia, or predisposes to fibromyalgia. Sample sizes for both groups are small – and the steps for selecting ‘normal’ controls isn’t well-described. The statistical tests lacked power, so that even moderate effect sizes didn’t reach significance. It’s also not clear whether any other groups of people with chronic pain have similar increased sensitivity.

What does it mean?

Well, apart from recognising that people with fibromyalgia are sensitive souls, it may point to a central neurobiological deficit in sensory processing. This may lead to future studies using fMRI, PECT and other imaging modalities to identify the specific areas of the brain that may be responsible for this sensitivity. It may lead to development of therapies similar to those used for developmental delay disorders such as sensory integration, or even a process of a graded desensitisation.

In the meantime, it might be helpful for people who have fibromyalgia to be aware of their tendency to become aware of and respond to sensory stimuli, and take steps to avoid ‘over-stimulation’. For example, it might be useful to wear sunglasses in glarey or bright light, to use earplugs when it is noisy (especially when trying to sleep), and to introduce new sensations such as fabric textures, tastes etc slowly.
Geisser, Glass, Rajcevska, Clauw, Williams, Kileny & Gracely (2008). A Psychophysical Study of Auditory and Pressure Sensitivity in Patients With Fibromyalgia and Healthy Controls, Journal of Pain, in press