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Chronic Widespread Pain

Chronic Widespread Pain. Joost Dekker Department of Rehabilitation Medicine VU University Medical Center Amsterdam, the Netherlands j.dekker@vumc.nl. Overview. Chronic Widespread Pain (CWP) Definition, assessment, epidemiology Psycho-biology Cognitive factors maintaining CWP

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Chronic Widespread Pain

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  1. Chronic Widespread Pain Joost Dekker Department of Rehabilitation Medicine VU University Medical Center Amsterdam, the Netherlands j.dekker@vumc.nl

  2. Overview Chronic Widespread Pain (CWP) • Definition, assessment, epidemiology • Psycho-biology • Cognitive factors maintaining CWP • Treatment of CWP

  3. Definition • Pain • In at least two contra-lateral limbs & • in the axial skeleton & • for at least 3 month ACR, 1990 • Fibromyalgia • Tenderpoints

  4. Assessment Hunt, Rheumatology, 1999

  5. Assessment • "Have you suffered from general pain during the last 3 months?" • "Did you have continuous pain during all 3 months?" • "Do you suffer from pain in both the upper and lower body?" • "Do you suffer from pain in both the right and left sides?” Kato et al., Arch Intern Med. 2006

  6. Epidemiology • Prevalence • 1 month population prevalence ~ 11 % Croft, 1999 • Comorbidities • Fatigue • Arthritis • Depression and anxiety • IBS • Allergy Kato, 2006

  7. Framework

  8. Biological and psychological mechanisms Central sensitisation • Pain • Fatigue • Activity limitations Figure 1 Central sensitisation and CWP Framework

  9. Cognitive factors: • Self efficacy • Cognitive coping strategies, including fear avoidance • Illness beliefs Biological and psychological mechanisms Central sensitisation • Pain • Fatigue • Activity limitations Figure 2 Cognitive factors maintaining CWP Framework

  10. Multidisciplinary rehabilitation • Cognitive factors: • Self efficacy • Cognitive coping strategies, including fear avoidance • Illness beliefs Biological and psychological mechanisms Central sensitisation • Pain • Fatigue • Activity limitations Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP Framework

  11. Multidisciplinary rehabilitation • Cognitive factors: • Self efficacy • Cognitive coping strategies, including fear avoidance • Illness beliefs Biological and psychological mechanisms Central sensitisation • Pain • Fatigue • Activity limitations Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP Framework

  12. Central sensitization Increased excitability of spinal and supraspinal neural circuits • Hyperalgesia • Noxious stimuli result in more pain than expected • Allodynia • Nonnoxious stimuli result in pain • Radiation • Spreading of pain • Temporal summation • Increased latency, after sensation Bennet, 1999

  13. Major neural pathways in pain processing Bennett R and Nelson D (2006) Cognitive behavioral therapy for fibromyalgia Nat Clin Pract Rheumatol2:416–424 doi:10.1038/ncprheum0245

  14. Multidisciplinary rehabilitation • Cognitive factors: • Self efficacy • Cognitive coping strategies, including fear avoidance • Illness beliefs Biological and psychological mechanisms Central sensitisation • Pain • Fatigue • Activity limitations Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP Framework

  15. Risk factors • Depression • Predicts onset of episode of pain Carroll, 2004 • Somatic symptoms and illness behavior • Predict onset of CWP McBeth, 2001 • Trauma • Separation from mother, or institutionalized as child predict onset of CWP in adulthood Jones, 2008

  16. Risk factors • Impaired sleep • Predicts onset of pain Canivet, 2008 • Predicts intensity of pain in CWP Bigatti, 2008 • Restorative sleep • Predicts resolution of CWP Davies, 2008

  17. Impaired sleep Canivet, 2008 • Cohort • 45 – 65 years • Baseline questionnaire • Exclusion of subjects with shoulder, neck, lumbar pain • Exclusion of subjects with medical conditions interfering with sleep • Follow up after 1 year

  18. Impaired sleep Canivet, 2008 • 1 year risk of chronic pain • 14.6% in women • 11.8% in men • Sleeping problems • 11.2% women • 7.6% men • Association ‘sleeping problems’ and ‘chronic pain’, controlling for confounders • OR= 1.92 in women • OR= 1.83 in men

  19. Risk factors for CWP • Depression • Somatic symptoms and illness behavior • Trauma • Impaired sleep

  20. Biological mechanisms • Hypothalamo-pituitary adrenal axis (HPA-axis): “stress system” • Dysfunction of HPA-axis predicts onset of CWP McBeth, 2007 • Autonomic nervous system ?

  21. HPA-axis McBeth, 2007 • Cohort • Baseline questionnaire • Exclusion of subjects with CWP • Selection of subjects at risk for CWP • Somatic symptoms and illness behavior • Assessment of HPA-axis, at baseline • Follow up after 15 months, questionnaire

  22. HPA-axis McBeth, 2007 • Onset of CWP at follow up • 11.6% • Influence of baseline HPA-axis • Subjects with CWP, compared to subjects without CWP • Higher cortisol level (post-dexamethasone) • Lower cortisol level in morning saliva • Higher cortisol level in evening saliva • Dysfunction of HPA axis predicts onset of CWP

  23. Summary 1 • Risk factors for CWP • Depression • Somatic symptoms and illness behavior • Trauma • Impaired sleep • Biological mechanisms • HPA-axis • Autonomic nervous system ?

  24. Multidisciplinary rehabilitation • Cognitive factors: • Self efficacy • Cognitive coping strategies, including fear avoidance • Illness beliefs Biological and psychological mechanisms Central sensitisation • Pain • Fatigue • Activity limitations Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP Framework

  25. Cohort study • Goal • To predict outcome of multidisciplinary rehabilitation in CWP, using psychological processes maintaining CWP • Patients • CWP • Aged > 18 and <75 • Assessment at • Pretreatment, 4 months post, 15 months post

  26. 1st Results • Cognitive concepts are considered to be separate entities, but are they ? • “Different psychological concepts related to pain may overlap and represent the same domain” Nielson and Jensen, 2004 • “There is a need for developing more comprehensive and integrative conceptual models” Keefe et al., 2004 • Goal: To explore overlap between cognitive concepts maintaining chronic pain derived from different models and to reduce these concepts into a more parsimonious model

  27. Cognitive factors maintaining CWP Self-efficacy • One’s confidence in performing a particular behavior and overcoming barriers to that behavior (Bandura). • I can always manage to solve difficult problems, if I try hard enough Illness perceptions • Ideas that patients hold about their illness (Leventhal) • My pain will last for a long time • I can do a lot to control and manage my pain

  28. Cognitive factors maintaining CWP Coping • Cognitive efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person (Lazarus and Folkman) • When I have pain I try to think about something nice Kinesiophobia / Fear-avoidance • Episode of pain can be interpreted as a signal for future pain and injury, resulting in pain-related fear and avoidance of activity (Lethem). • It is not safe for a person with a condition like mine to be physically active

  29. Method • Measures • Self-efficacy • Dutch General Self-efficacy Scale (DGSS) • Illness perceptions • Illness Perception Questionnaire-Revised (IPQ-R) • Cognitive coping styles • Dutch Coping with Pain Questionnaire (CPV) • Kinesiophobia • Tampa Scale of Kinesiophobia (TSK) • Factor analysis • Explorative, Orthogonal

  30. Results • N = 134 • 92.5% women • Age: 46 ± 11 years • 75.4% Dutch ethnicity • Pain (0-10): 6.2 ± 2.1 • Fatigue (0-10): 8.3 ± 1.6

  31. Results of factor analysis

  32. Summary 2 • Variety of cognitive concepts maintaining CWP can be reduced to • negative emotional cognitions • active cognitive coping • control beliefs and expectancies of chronicity

  33. Multidisciplinary rehabilitation • Cognitive factors: • Self efficacy • Cognitive coping strategies, including fear avoidance • Illness beliefs Biological and psychological mechanisms Central sensitisation • Pain • Fatigue • Activity limitations • Depression Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP

  34. Treatment • EULAR recommendations for management of fibromyalgia • Systematic review of high quality studies • Delphi procedure Carville, 2008

  35. EULAR: non-pharmacological management

  36. EULAR: pharmacological management

  37. Multicomponent treatment of fibromyalgia • Multicomponent • At least 1 educational therapy + at least 1 exercise therapy • Systematic review • Strong evidence for short effect of multicomponent treatment on • Pain • Fatigue • Depressive symptoms • QoL • Self efficacy pain • Physical fitness Hauser, 2009

  38. Summary 3 • Treatment • Nonpharmacological • Pharmacological • Multicomponent

  39. Multidisciplinary rehabilitation • Cognitive factors: • Self efficacy • Cognitive coping strategies, including fear avoidance • Illness beliefs Biological and psychological mechanisms Central sensitisation • Pain • Fatigue • Activity limitations Figure 3 Multidisciplinary Rehabilitation and Cognitive Factors affecting CWP Framework

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