Multidimensional characteristics of musculoskeletal pain and risk of hip fractures among elderly adults: the first longitudinal evidence from CHARLS.

BACKGROUND: Hip fractures are a major public health concern among middle-aged and older adults. It is important to understand the associated risk factors to inform health policies and develop better prevention strategies. Musculoskeletal pain is a possible implicating factor, being associated with physical inactivity and risk of falls. However, the association between musculoskeletal pain and hip fractures has not been clearly investigated. METHODS: A nationally representative sample of the Chinese population was obtained from the China Health and Retirement Longitudinal Study (CHARLS). The study collected patient information on their demographic characteristics, socioeconomic status, other health-related behavior, and history of musculoskeletal pain and hip fractures. Univariate and multivariate analyses were conducted to investigate the factors influencing the risk of hip fracture, including factors related to the individual and to musculoskeletal pain. P for trend test was performed to assess the trend of each continuous variable. The robustness and bias were assessed using the bootstrap method. Restricted cubic spline regression was utilized to identify linear or non-linear relationships. RESULTS: Among the 18,813 respondents, a total of 215 individuals reported that they have experienced a hip fracture. An increased risk of hip fracture was associated with the presence of waist pain and leg pain (P < 0.05), as well as with an increased number of musculoskeletal pain sites (P < 0.05). For individuals aged 65 and above, a significant association was found between age and the risk of hip fracture (P < 0.05). Furthermore, respondents with lower education level had a higher risk of hip fracture compared to those with higher education levels (P < 0.05). CONCLUSION: In the Chinese population, the risk of hip fracture was found to be associated with both the location and extent of musculoskeletal pain, as well as with other factors such as age and demographic characteristics. The findings of this study may be useful for informing policy development and treatment strategies, and provide evidence for comparison with data from other demographic populations.

A precision-based exercise program for patients with multiple myeloma.

OBJECTIVES: Aim of this study was to retrospectively evaluate an interdisciplinary consultation followed by a precision-based exercise program (PEP) for myeloma patients with stable and unstable bone lesions. METHODS: Data of myeloma patients (n = 100) who received a PEP according to an orthopedic evaluation were analyzed. Bone stability was assessed by established scoring systems (Spinal Instability Neoplastic Score [SINS], Mirels' score). All patients with stable and unstable osteolyses received a PEP and n = 91 were contacted for a follow-up interview. RESULTS: In 60% of patients at least one osteolysis of the spine was considered potentially unstable or unstable. Following consultation, the number of patients performing resistance training could be significantly increased (≥2 sessions/week, 55%). Musculoskeletal pain was reported frequently. At the follow-up interview, 75% of patients who performed PEP stated that painful symptoms could be effectively alleviated by exercise. Moreover, only patients who exercised regularly discontinued pain medication. No injuries were reported in association with PEP. CONCLUSION: We were able to demonstrate that individualized resistance training is implementable and safe for myeloma patients. By means of a PEP, patients' self-efficacy in managing musculoskeletal pain was enhanced and pain medication could be reduced.

Pharmacological Interventions Targeting Pain in Fibrous Dysplasia/McCune-Albright Syndrome.

Fibrous dysplasia (FD) is a rare, non-inherited bone disease occurring following a somatic gain-of-function R201 missense mutation of the guanine-nucleotide binding protein alpha subunit stimulating activity polypeptide 1 (GNAS) gene. The spectrum of the disease ranges from a single FD lesion to a combination with extraskeletal features; an amalgamation with café-au-lait skin hyperpigmentation, precocious puberty, and other endocrinopathies defines McCune-Albright Syndrome (MAS). Pain in FD/MAS represents one of the most prominent aspects of the disease and one of the most challenging to treat-an outcome driven by (i) the heterogeneous nature of FD/MAS, (ii) the variable presentation of pain phenotypes (i.e., craniofacial vs. musculoskeletal pain), (iii) a lack of studies probing pain mechanisms, and (iv) a lack of rigorously validated analgesic strategies in FD/MAS. At present, a range of pharmacotherapies are prescribed to patients with FD/MAS to mitigate skeletal disease activity, as well as pain. We analyze evidence guiding the current use of bisphosphonates, denosumab, and other therapies in FD/MAS, and also discuss the potential underlying pharmacological mechanisms by which pain relief may be achieved. Furthermore, we highlight the range of presentation of pain in individual cases of FD/MAS to further describe the difficulties associated with employing effective pain treatment in FD/MAS. Potential next steps toward identifying and validating effective pain treatments in FD/MAS are discussed, such as employing randomized control trials and probing new pain pathways in this rare bone disease.

The temporal relation between pain and fatigue in individuals receiving treatment for chronic musculoskeletal pain.

BACKGROUND: Numerous investigations have revealed significant relations between pain and fatigue in individuals with persistent pain conditions. However, the direction of influence between pain and fatigue remains unclear. Shortcomings of design and analytic approaches used in previous research limit the nature of conclusions that can be drawn about possible causal or directional relations between pain and fatigue. The present study investigated the temporal relation between changes in pain and changes in fatigue in individuals with musculoskeletal pain enrolled in a 10-week behavioral activation intervention. On the basis of previous findings, it was hypothesized that analyses would support a bi-directional relation between pain and fatigue. METHODS: The study sample consisted of 104 individuals with chronic musculoskeletal pain participating in a 10-week standardized rehabilitation intervention. Measures of pain intensity and fatigue were completed pre-, mid-, and post-treatment. The three-wave data panel permitted examination of the direction of influence between pain and fatigue through the course of the intervention. A random-intercept cross-lagged panel model (RI-CLPM) was used to examine the temporal relation between pain and fatigue. RESULTS: Consistent with previous research, cross-sectional analyses of pre-treatment data revealed significant correlations between measures of pain and fatigue. Significant reductions in pain and fatigue were observed through the course of treatment (d = 0.33 and d = 0.66, p < .001, respectively). RI-CLPM revealed that pain severity predicted later fatigue (pre to mid-treatment standardized path coefficient (ß) = 0.55, p = 0.02; mid to post-treatment ß = 0.36, p = 0.001); however, fatigue did not predict later pain severity. CONCLUSIONS: Discussion addresses the processes that might underlie the temporal relation between pain and fatigue. Clinical implications of the findings are also discussed.

Classification of kneeling and squatting in workers wearing protective equipment: development and validation of a rule-based model using wireless triaxial accelerometers.

Several professions in industries, such as petroleum, manufacturing, construction, mining, and forestry require prolonged work tasks in awkward postures, increasing workers' risks for musculoskeletal pain and injury. Therefore, we developed and validated a rule-based model for classifying unilateral and bilateral kneeling and squatting based on 15 individuals wearing personal protective equipment and using three wireless triaxial accelerometers. The model provided both high sensitivity and specificity for classifying kneeling (0.98; 0.98) and squatting (0.96; 0.91). Hence, this model has the potential to contribute to increased knowledge of physical work demands and exposure thresholds in working populations with strict occupational safety regulations. Practitioner summary: Our results indicate that this rule-based model can be applied in a human-factors perspective enabling high-quality quantitative information in the classification of occupational kneeling and squatting, known risk factors for musculoskeletal pain, and sick leave. This study is adapted for working populations wearing personal protective equipment and aimed for long-term measurements in the workplace.

Is musculoskeletal pain related to locomotive syndrome even in young and middle-aged adults?

OBJECTIVES: Locomotive syndrome (LS) is the leading cause of persons needing long-term care in old age and is characterized by locomotive organ impairment including musculoskeletal pain. The aim was to examine the association between musculoskeletal pain and LS in young and middle-aged persons. METHODS: A total of 836 participants (male 667, female 169; mean age 44.4 years) were examined in this cross-sectional study. The LS was evaluated by three screening tools: the two-step test, the stand-up test, and the 25-question Geriatric Locomotive Function Scale. Musculoskeletal pain, exercise habits, physical function (walkability and muscle strength), and physical activity were also assessed. RESULTS: The LS was found in 22.8% of participants. The number with musculoskeletal pain was significantly higher in those with the LS. A significant correlation was found between the degree of musculoskeletal pain and exercise habits. Less regular exercise was significantly associated with higher LS prevalence. Physical activity and function were greater in participants with more regular exercise. CONCLUSION: Musculoskeletal pain was significantly related to LS even in young and middle-aged persons. The present results suggest that control of musculoskeletal pain and improvement of exercise habits in young and middle-aged persons might help prevent the LS.

Reduced specific force in patients with mild and severe facioscapulohumeral muscular dystrophy.

BACKGROUND: Specific force, that is the amount of force generated per unit of muscle tissue, is reduced in patients with facioscapulohumeral muscular dystrophy (FSHD). The causes of reduced specific force and its relation with FSHD disease severity are unknown. METHODS: Quantitative muscle magnetic resonance imaging (MRI), measurement of voluntary maximum force generation and quadriceps force-frequency relationship, and vastus lateralis muscle biopsies were performed in 12 genetically confirmed patients with FSHD and 12 controls. RESULTS: Specific force was reduced by ~33% in all FSHD patients independent of disease severity. Quadriceps force-frequency relationship shifted to the right in severe FSHD compared to controls. Fiber type distribution in vastus lateralis muscle biopsies did not differ between groups. CONCLUSIONS: Reduced quadriceps specific force is present in all FSHD patients regardless of disease severity or fatty infiltration. Early myopathic changes, including fibrosis, and non-muscle factors, such as physical fatigue and musculoskeletal pain, may contribute to reduced specific force.

Daily associations between sleep and pain in patients with chronic musculoskeletal pain.

Patients with chronic pain commonly report sleep problems, and the evidence for a relationship between sleep disturbance and pain seems robust. The day-to-day associations between these constructs are less well studied, particularly with objective sleep measures such as actigraphy. Moreover, the concurrent presence of negative affective symptoms, as well as seasonality effects at extreme latitudes may complicate it further. Here, we studied 56 patients with chronic primary musculoskeletal pain conditions, contributing data in two separate 7-day data-collection periods during the summer and winter, respectively. The effect of self-reported sleep quality, and actigraphy measured sleep duration, efficiency and timing on next-day pain, as well as the effect of pain on the same sleep indices were estimated by generalised linear mixed regression models. The models were additionally adjusted for age, sex, education, data collection period, weekend, season and mental distress, with the latter two also specified as moderators. We observed a significant effect of pain as a predictor of next-night sleep quality (p = .003) and marginally of next-night sleep duration (p = .079). Conversely, sleep quality tentatively predicted next-day pain (p = .063). No other day-to-day associations were present. Mental distress was the strongest predictor of pain, but it did not modify the sleep-pain associations, nor did season. In conclusion pain, sleep quality and mental distress are closely related, underscoring the importance of encompassing this complexity in assessment and treatment of patients with chronic pain.

Translation and cross-cultural adaptation of Nepali versions of the Patient-Reported Outcomes Measurement Information System (PROMIS®) Pain Intensity, Pain Interference, Pain Behavior, Depression, and Sleep Disturbance short forms in chronic musculoskeletal pain.

PURPOSE: The Patient-Reported Outcomes Meaurement Information System (PROMIS®) measures have been translated into many languages and have been shown to have strong measurement properties across a wide range of clinical conditions. However, Nepali translations of the PROMIS short forms are not yet available. The aim of this study was to translate and cross-culturally adapt the PROMIS Pain Intensity, Pain Interference, Pain Behavior, Depression, and Sleep Disturbance short forms into Nepali. METHODS: We used the Functional Assessment of Chronic Illness Therapy (FACIT) translation methodology, which incorporated two forward translations, synthesis of the translations, a back-translation, and three independent reviews, harmonization, cognitive debriefing, revisions, and proof reading. The translation and review teams were fluent in Nepali and English and represented five different countries and four continents. We evaluated the short forms for comprehensibility and relevance (two key aspects of the content validity of an instrument), conducting cognitive debriefing with six adults with chronic musculoskeletal pain, in compliance with recommendations by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). The final version was proofread by two native Nepali speakers before and three new proofreaders after cognitive debriefing. RESULTS: All five short forms were successfully translated and cross-culturally adapted into Nepali while maintaining equivalence to the source. CONCLUSIONS: The translation and review team, along with a sample from the target population with chronic musculoskeletal pain and the proofreaders considered all five PROMIS short forms relevant and comprehensible. An important next step is to evaluate the measurement properties of these instruments.

Scurvy Masquerading as Juvenile Idiopathic Arthritis or Vasculitis with Elevated Inflammatory Markers: A Case Series.

Ten patients with scurvy were evaluated by rheumatology; we review their clinical, laboratory, and dietary presentations. Eight patients had developmental delay or autism. All had elevated inflammatory markers. These clinical and laboratory features with imaging findings can mimic rheumatic conditions such as arthritis, vasculitis, and chronic nonbacterial osteomyelitis (CNO).

Co-occurrence of pain syndromes.

Many pain conditions in patients tend to co-occur, influencing the clinical expressions of each other in various ways. This paper summarizes the main concurrent pain conditions by analyzing the major interactions observed. In particular, co-occurrence will be examined in: visceral pain (especially ischemic heart disease, irritable bowel syndrome, dysmenorrhea/endometriosis and urinary pain), fibromyalgia, musculoskeletal pain and headache. Two concurrent visceral pains from internal organs sharing at least part of their central sensory projection can give rise to viscero-visceral hyperalgesia, i.e., enhancement of typical pain symptoms from both districts. Visceral pain, headache and musculoskeletal pains (myofascial pain from trigger points, joint pain) can enhance pain and hyperalgesia from fibromyalgia. Myofascial pain from trigger points can perpetuate pain symptoms from visceral pain conditions and trigger migraine attacks when located in the referred pain area from an internal organ or in cervico-facial areas, respectively. The pathophysiology of these pain associations is complex and probably multifactorial; among the possible processes underlying the mutual influence of symptoms recorded in the associations is modulation of central sensitization phenomena by nociceptive inputs from one or the other condition. A strong message in these pain syndrome co-occurrence is that effective treatment of one of the conditions can also improve symptoms from the other, thus suggesting a systematic and thorough evaluation of the pain patient for a global effective management of his/her suffering.

Translation, cross-cultural adaptation, and measurement properties of the Nepali version of the central sensitization inventory (CSI).

BACKGROUND: Central sensitization is thought to be an important contributing factor in many chronic pain disorders. The Central Sensitization Inventory (CSI) is a patient-reported measure frequently used to assess symptoms related to central sensitization. The aims of the study were to translate and cross-culturally adapt the CSI into Nepali (CSI-NP) and assess its measurement properties. METHODS: The CSI was translated into Nepali using recommended guidelines. The CSI-NP was then administered on 100 Nepalese adults with sub-acute and chronic musculoskeletal pain with additional demographic and pain-related questions. The CSI-Nepali was administered again about 2 weeks later. Four measurement properties of the CSI-NP were evaluated: (1) internal consistency using Cronbach's alpha, (2) test-retest reliability using intraclass correlation coefficient (ICC2,1), (3) measurement errors, and (4) construct validity testing five a priori hypotheses. Confirmation of construct validity was determined if a minimum of 75% of the hypotheses were met. RESULTS: The CSI was successfully translated into Nepali. Internal consistency and test-retest reliability were both excellent (Cronbach's alpha = 0.91, and ICC = 0.98). The standard error of measurement was 0.31 and the smallest detectable change was 0.86. Four out of five (80%) a priori hypotheses were met, confirming the construct validity: the CSI-NP correlated strongly with the Pain Catastrophizing Scale total scores (r = 0.50); moderately with the total number of pain descriptors (r = 0.35); weakly with the Numerical Rating Scale (r = 0.25); and women had significantly higher CSI scores than men. However, the CSI scores did not correlate significantly with the total duration of pain, as hypothesized (r = 0.10). CONCLUSIONS: The Nepali translation of the CSI demonstrated excellent reliability and construct validity in adults with musculoskeletal pain. It is now available to Nepali health care providers to help assess central sensitization-related signs and symptoms in individuals with musculoskeletal pain in research or clinical practice to advance the understanding of central sensitization in Nepalese samples.

Investigating musculoskeletal health and wellbeing; a cohort study protocol.

BACKGROUND: In an ageing population, pain, frailty and disability frequently coexist across a wide range of musculoskeletal diagnoses, but their associations remain incompletely understood. The Investigating Musculoskeletal Health and Wellbeing (IMH&W) study aims to measure and characterise the development and progression of pain, frailty and disability, and to identify discrete subgroups and their associations. The survey will form a longitudinal context for nested research, permitting targeted recruitment of participants for qualitative, observational and interventional studies; helping to understand recruitment bias in clinical studies; and providing a source cohort for cohort randomised controlled trials. METHODS: IMH&W will comprise a prospective cohort of 10,000 adults recruited through primary and secondary care, and through non-clinical settings. Data collection will be at baseline, and then through annual follow-ups for 4 years. Questionnaires will address demographic characteristics, pain severity (0-10 Numerical Rating Scale), pain distribution (reported on a body Manikin), pain quality (McGill Pain Questionnaire), central aspects of pain (CAP-Knee), frailty and disability (based on Fried criteria and the FRAIL questionnaire), and fracture risk. Baseline characteristics, progression and associations of frailty, pain and disability will be determined. Discrete subgroups and trajectories will be sought by latent class analysis. Recruitment bias will be explored by comparing participants in nested studies with the eligible IMH&W population. DISCUSSION: IMH&W will elucidate associations and progression of pain, frailty and disability. It will enable identification of people at risk of poor musculoskeletal health and wellbeing outcomes who might be suitable for specific interventions, and facilitate generalisation and comparison of research outcomes between target populations. The study will benefit from a large sample size and will recruit from diverse regions across the UK. Purposive recruitment will enrich the cohort with people with MSK problems with high representation of elderly and unwell people. TRIAL REGISTRATION: Clinicaltrials.gov NCT03696134. Date of Registration: 04 October 2018.

Frequent Headaches: Evaluation and Management.

Most frequent headaches are typically migraine or tension-type headaches and are often exacerbated by medication overuse. Repeated headaches can induce central sensitization and transformation to chronic headaches that are intractable, are difficult to treat, and cause significant morbidity and costs. A complete history is essential to identify the most likely headache type, indications of serious secondary headaches, and significant comorbidities. A headache diary can document headache frequency, symptoms, initiating and exacerbating conditions, and treatment response over time. Neurologic assessment and physical examination focused on the head and neck are indicated in all patients. Although rare, serious underlying conditions must be excluded by the patient history, screening tools such as SNNOOP10, neurologic and physical examinations, and targeted imaging and other assessments. Medication overuse headache should be suspected in patients with frequent headaches. Medication history should include nonprescription analgesics and substances, including opiates, that may be obtained from others. Patients who overuse opiates, barbiturates, or benzodiazepines require slow tapering and possibly inpatient treatment to prevent acute withdrawal. Patients who overuse other agents can usually withdraw more quickly. Evidence is mixed on the role of medications such as topiramate for patients with medication overuse headache. For the underlying headache, an individualized evidence-based management plan incorporating pharmacologic and nonpharmacologic strategies is necessary. Patients with frequent migraine, tension-type, and cluster headaches should be offered prophylactic therapy. A complete management plan includes addressing risk factors, headache triggers, and common comorbid conditions such as depression, anxiety, substance abuse, and chronic musculoskeletal pain syndromes that can impair treatment effectiveness. Regular scheduled follow-up is important to monitor progress.

Erythema Ab Igne in an Adolescent With Chronic Pain: An Alarming Cutaneous Eruption From Heat Exposure.

Erythema ab igne (EAI) is a cutaneous finding caused by prolonged heat exposure and is characterized by a reticular, brownish-pigmented, often telangiectatic dermatosis. The eruption is reminiscent of livedo reticularis, which is typically seen in the setting of a number of rheumatologic conditions, most prominently vasculitis. Identification of key features distinguishing EAI from livedo reticularis can aid in the diagnosis of EAI and correct elucidation of the underlying etiology. Our patient presented with heating pad-induced EAI in the setting of chronic pain. Only 6 other pediatric cases of EAI associated with heat sources for chronic pain are reported (Acta Derm Venereol. 2014;94:365-367, J Pediatr. 2013;163:1789, Int J Eat Disord. 2013;46:381-383, Arch Dis Child. 2008;93:389, Arch Pediatr Adolesc Med. 2012;166:185-186, Br J Clin Pract. 1990;44:248-251). Our case highlights the need for awareness of this pathognomonic skin eruption in children with chronic pain conditions to help avoid an extensive workup for vasculitis.

Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care.

OBJECTIVES: Post-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care. METHODS: A cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression. RESULTS: We identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis. CONCLUSION: Post-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.

Central Sensitization Inventory Mediates the Relationship Between Inflammatory Bowel Disease Activity and Worse Musculoskeletal Pain Experiences.

BACKGROUND: Musculoskeletal conditions are well documented in inflammatory bowel disease (IBD). However, whether IBD activity influences musculoskeletal pain experiences is uncertain. Central sensitization has been proposed in patients with IBD who are suffering from persistent pain. Identification of central sensitization symptomology using the Central Sensitization Inventory (CSI) has been reported in many pain-related disorders. Aims of this study were to explore predictive relationships between IBD activity and musculoskeletal pain experiences (severity/interference), and the mediating effects of the CSI. METHODS: A cross-sectional online survey was performed exploring self-reported musculoskeletal pain in adults with IBD. Survey questionnaires included IBD activity indices, numeric rating scales, PROMIS Pain Interference, and the CSI. Linear regression was used to examine the relationship between active IBD and pain experiences. Simple and serial mediation analyses were used to explore mediation models: independent variable (IBD activity), dependent variables (severity/interference), and mediators (CSI/severity). RESULTS: 208 adults with IBD, 18 to 88 years of age, reported musculoskeletal pain. Regression analysis identified IBD activity as a significant predictor of worse pain severity (R2  = 0.039, P < 0.005) and interference (R2  = 0.067, P < 0.001). Simple mediation showed a significant indirect effect from CSI scores between IBD activity and pain severity. Serial mediation analysis showed a significant indirect effect from CSI scores and pain severity, between IBD activity and pain interference. CONCLUSION: Active IBD demonstrated a positive association with worse musculoskeletal pain experiences. The CSI demonstrated significant mediation between active IBD and pain severity. Additionally, the CSI and pain severity demonstrated significant mediation between active IBD and pain interference. This suggests that symptoms of central sensitization significantly influence musculoskeletal pain experiences in IBD.

Central sensitization predicts greater fatigue independently of musculoskeletal pain.

OBJECTIVES: To test whether central sensitization was associated with greater fatigue, independently of musculoskeletal pain. METHODS: 2477 prospective cohort study participants completed a baseline questionnaire comprising the Chalder Fatigue Scale (CFQ), pain, demographics, physical activity, anxiety, depression and medication use. In a clinical assessment of 290 (11.7%) participants, central sensitization was measured by the wind-up ratio test at the hand (WUR-H) and foot (WUR-F). Bioelectric impedance determined proportion body fat. All participants were followed up 12 months later, at which time they completed the CFQ. Linear regression, with inverse probability sampling weights, tested the relationship between WUR at baseline and CFQ at 12 months, adjusted for baseline CFQ, demographics, lifestyle factors, mental health and baseline pain. RESULTS: At baseline, the median interquartile range WUR-H and WUR-F were similar (2.3 (1.5, 4.0) and 2.4 (1.6, 3.9) respectively) and did not differ by sex (difference WUR-H: -0.29, 95% confidence interval -1.28-0.71; WUR-F: -0.57 (-1.50-0.36) or age(WUR-H: -0.53, -1.49-0.43; WUR-F:-0.08, -0.98-0.82). WUR-H scores (ß = 0.11, 95% confidence interval: 0.07-0.16) and WUR-F scores (0.13, 0.08-0.17) were positively associated with CFQ scores at follow-up, independently of baseline CFQ and other covariates. These associations were not explained by baseline pain. CONCLUSION: Fatigue was predicted by central sensitization, independently of the presence of pain. For those seeking to treat fatigue, the benefit of interventions that reduce central sensitization should be investigated.

Automated Self-management (ASM) vs. ASM-Enhanced Collaborative Care for Chronic Pain and Mood Symptoms: the CAMMPS Randomized Clinical Trial.

BACKGROUND: Chronic musculoskeletal pain is often accompanied by depression or anxiety wherein co-occurring pain and mood symptoms can be more difficult to treat than either alone. However, few clinical trials have examined interventions that simultaneously target both pain and mood conditions. OBJECTIVE: To determine the comparative effectiveness of automated self-management (ASM) vs. ASM-enhanced collaborative care. DESIGN: Randomized clinical trial conducted in six primary care clinics in a VA medical center. PARTICIPANTS: Two hundred ninety-four patients with chronic musculoskeletal pain of at least moderate intensity and clinically significant depressive and/or anxiety symptoms. INTERVENTION: ASM consisted of automated monitoring and 9 web-based self-management modules. Comprehensive symptom management (CSM) combined ASM with collaborative care management by a nurse-physician team. Both interventions were delivered for 12 months. MAIN MEASURES: Primary outcome was a composite pain-anxiety-depression (PAD) z-score consisting of the mean of the BPI, PHQ-9, and GAD-7 z-scores: 0.2, 0.5, and 0.8 represent potentially small, moderate, and large clinical differences. Secondary outcomes included global improvement, health-related quality of life, treatment satisfaction, and health services use. KEY RESULTS: Both CSM and ASM groups had moderate PAD score improvement at 12 months (z = - 0.65 and - 0.52, respectively). Compared to the ASM group, the CSM group had a - 0.23 (95% CI, - 0.38 to - 0.08; overall P = .003) greater decline in composite PAD z-score over 12 months. CSM patients were also more likely to report global improvement and less likely to report worsening at 6 (P = .004) and 12 months (P = .013). CONCLUSIONS: Two intervention models relying heavily on telecare delivery but differing in resource intensity both produced moderate improvements in pain and mood symptoms. However, the model combining collaborative care led by a nurse-physician team with web-based self-management was superior to self-management alone. TRIAL REGISTRATION: ClinicalTrials.gov : NCT0175730.

Patients with Chronic Musculoskeletal Pain of 3-6-Month Duration Already Have Low Levels of Health-Related Quality of Life and Physical Activity.

PURPOSE OF REVIEW: To determine the level of physical activity and health-related quality of life in patients with chronic musculoskeletal pain of 3-6-month duration who have not been diagnosed or treated before. RECENT FINDINGS: Low levels of quality of life and physical activity have been reported for patients with musculoskeletal pain with a duration of longer than 6 months. This study assessed the levels of quality of life and physical activity at the beginning stage of chronic musculuskeletal pain. Prospective cross-sectional study carried out at a musculoskeletal and sports medicine clinic. Eighty-five consecutive patients with muskuloskeletal (i.e., spine, peripheral joint, muscle, tendon) pain of 3-6-month duration, not diagnosed before, age 14 and older, and from either gender were recruited. Short Form-36 Health Survey and International Physical Activity Questionnaire long were administered during assessments. Scores on subscales of Short Form-36 Health Survey and total scores of International Physical Activity Questionnaire were used as outcome measures. A total of 85 patients with an age range of 15-86 (51.22 ± 15.99) were enrolled. There were 23 male (27.06%) and 62 (72.94%) female subjects. Forty-six (54.11%) patients had three or less painful regions; 39 (45.88%) had more than three painful regions. Majority of the patients had low scores on both Short Form-36 Health Survey subscales and International Physical Activity Questionnaire. Forty-nine patients had low, 32 patients had moderate, and 4 patients had high level of physical activity. Overall, females had lower level of physical activity in all age groups. All patients had less than optimal scores on all subscales of Physical Health and Mental Health scales of the Short Form-36. The female patients had lower scores in role physical and bodily pain subscales of physical health. Patients with musculoskeletal pain duration of 3-6 months have low levels of physical activity and health-related quality of life at the time of their first evaluation.