Chronic Widespread Pain

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Chronic Widespread Pain. Joost Dekker Department of Rehabilitation Medicine VU University Medical Center Amsterdam, the Netherlands [email protected] Overview. Chronic Widespread Pain (CWP) Definition, assessment, epidemiology Psycho-biology Cognitive factors maintaining CWP - PowerPoint PPT Presentation

Transcript of Chronic Widespread Pain

  • Chronic Widespread PainJoost DekkerDepartment of Rehabilitation Medicine VU University Medical CenterAmsterdam, the [email protected]

  • Overview

    Chronic Widespread Pain (CWP)Definition, assessment, epidemiologyPsycho-biologyCognitive factors maintaining CWPTreatment of CWP

  • DefinitionPain In at least two contra-lateral limbs & in the axial skeleton&for at least 3 month ACR, 1990FibromyalgiaTenderpoints

  • Assessment

    Hunt, Rheumatology, 1999

  • 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

  • Epidemiology

    Prevalence1 month population prevalence ~ 11 % Croft, 1999ComorbiditiesFatigueArthritisDepression and anxietyIBSAllergy Kato, 2006

  • Framework

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  • Central sensitizationIncreased excitability of spinal and supraspinal neural circuitsHyperalgesia Noxious stimuli result in more pain than expectedAllodyniaNonnoxious stimuli result in painRadiationSpreading of painTemporal summationIncreased latency, after sensation Bennet, 1999

  • Major neural pathways in pain processingBennett R and Nelson D (2006) Cognitive behavioral therapy for fibromyalgia Nat Clin Pract Rheumatol 2: 416424 doi:10.1038/ncprheum0245

  • Framework

  • Risk factorsDepressionPredicts onset of episode of pain Carroll, 2004Somatic symptoms and illness behaviorPredict onset of CWP McBeth, 2001

    TraumaSeparation from mother, or institutionalized as child predict onset of CWP in adulthood Jones, 2008

  • Risk factorsImpaired sleepPredicts onset of pain Canivet, 2008Predicts intensity of pain in CWP Bigatti, 2008

    Restorative sleep Predicts resolution of CWP Davies, 2008

  • Impaired sleep Canivet, 2008Cohort 45 65 yearsBaseline questionnaireExclusion of subjects with shoulder, neck, lumbar pain Exclusion of subjects with medical conditions interfering with sleepFollow up after 1 year

  • Impaired sleep Canivet, 20081 year risk of chronic pain14.6% in women11.8% in menSleeping problems11.2% women7.6% menAssociation sleeping problems and chronic pain, controlling for confoundersOR= 1.92 in womenOR= 1.83 in men

  • Risk factors for CWP

    DepressionSomatic symptoms and illness behaviorTraumaImpaired sleep

  • Biological mechanisms

    Hypothalamo-pituitary adrenal axis (HPA-axis): stress system Dysfunction of HPA-axis predicts onset of CWP McBeth, 2007

    Autonomic nervous system ?

  • HPA-axis McBeth, 2007CohortBaseline questionnaireExclusion of subjects with CWPSelection of subjects at risk for CWPSomatic symptoms and illness behaviorAssessment of HPA-axis, at baselineFollow up after 15 months, questionnaire

  • HPA-axis McBeth, 2007Onset of CWP at follow up11.6%Influence of baseline HPA-axisSubjects with CWP, compared to subjects without CWPHigher cortisol level (post-dexamethasone)Lower cortisol level in morning salivaHigher cortisol level in evening salivaDysfunction of HPA axis predicts onset of CWP

  • Summary 1Risk factors for CWPDepressionSomatic symptoms and illness behaviorTraumaImpaired sleepBiological mechanismsHPA-axisAutonomic nervous system ?

  • Framework

  • Cohort studyGoalTo predict outcome of multidisciplinary rehabilitation in CWP, using psychological processes maintaining CWPPatients CWPAged > 18 and
  • 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, 2004There is a need for developing more comprehensive and integrative conceptual models Keefe et al., 2004Goal: To explore overlap between cognitive concepts maintaining chronic pain derived from different models and to reduce these concepts into a more parsimonious model

  • Cognitive factors maintaining CWP Self-efficacyOnes 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 perceptionsIdeas 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

  • Cognitive factors maintaining CWPCopingCognitive 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-avoidanceEpisode 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

  • MethodMeasuresSelf-efficacyDutch General Self-efficacy Scale (DGSS)Illness perceptionsIllness Perception Questionnaire-Revised (IPQ-R)Cognitive coping stylesDutch Coping with Pain Questionnaire (CPV)KinesiophobiaTampa Scale of Kinesiophobia (TSK)Factor analysis Explorative, Orthogonal

  • ResultsN = 134

    92.5% womenAge: 46 11 years75.4% Dutch ethnicity

    Pain (0-10): 6.2 2.1Fatigue (0-10): 8.3 1.6

  • Results of factor analysis



    Negative emotional cognitions

    Active cognitive coping

    Control beliefs and expectancies of chronicity

    IPQ Personal control


    IPQ Treatment control


    IPQ Illness coherence


    IPQ Consequence



    IPQ Emotional representation


    IPQ Timeline


    IPQ Timeline cyclical


    CPV Catastrophizing


    CPV Perceived pain control



    CPV Denial pain sensations


    CPV positive self statements


    CPV Reinterpreting pain


    CPV Praying and hoping


    CPV Diverting attention


    TSK Fear and avoidance


    DGSS General self efficacy






    Explained variance




  • Summary 2

    Variety of cognitive concepts maintaining CWP can be reduced tonegative emotional cognitionsactive cognitive coping control beliefs and expectancies of chronicity

  • Treatment

    EULAR recommendations for management of fibromyalgiaSystematic review of high quality studiesDelphi procedure Carville, 2008

  • EULAR: non-pharmacological management

  • EULAR: pharmacological management

  • Multicomponent treatment of fibromyalgiaMulticomponentAt least 1 educational therapy + at least 1 exercise therapySystematic reviewStrong evidence for short effect of multicomponent treatment on PainFatigueDepressive symptomsQoLSelf efficacy painPhysical fitness Hauser, 2009

  • Summary 3


  • Framework

    The title is slightly different than in the abstract as I wanted to focus on the subject of this sessionHow did the research population look.

    Of the 134 subjects, 93% were female and 7.5% were male. The Subjects were predominantly middle aged, and of Dutch ethnicity. Patients scored high on both experienced pain intensity and fatigue.