Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: two sides of the same coin?

OBJECTIVE: To date, few results on well-being in chronic-pain patients have been published, while several studies in patients without pain have indicated that well-being may not be equivalent to absence of psychological distress. The aim of the present study was to investigate the relationship between psychological distress and well-being and to identify the predictors of each in patients with chronic nonmalignant pain. METHODS: Sixty-nine women with chronic multiregional musculoskeletal pain, 41 of whom met American College of Rheumatology criteria for fibromyalgia, completed questionnaires on pain, fatigue, stiffness, physical disability (Fibromyalgia Impact Questionnaire), psychological distress [Multidimensional Affect and Pain Survey (MAPS), Symptom Check List-90 (SCL-90), State-Trait Anxiety Inventory Form Y2 (STAI-Y2)], and hedonic and eudaimonic well-being (MAPS). RESULTS: Patients reported increased amounts of psychological distress (STAI-Y2 and SCL-90) compared to healthy people. Multiple regression analysis of patient data demonstrated that higher psychological distress was related to higher age, more intense pain, a higher positive tender point count, and more physical disability. Well-being (both hedonic and eudaimonic aspects) decreased with higher disability, but was independent of age, pain intensity, and number of positive tender points. Bivariate correlations showed that psychological distress was moderately related to eudaimonic well-being and strongly related to positive affect, an aspect of hedonic well-being. CONCLUSION: In patients with chronic musculoskeletal pain, self-reports of well-being and low psychological distress only partially overlap with each other and are differently related to major patient symptoms, supporting the relevance of the concept of well-being to chronic-pain research and a need for further studies in this field.

Changes in salivary cortisol and corticosteroid receptor-alpha mRNA expression following a 3-week multidisciplinary treatment program in patients with fibromyalgia.

The aim of the present study was to investigate the effects of a 3-week residential multidisciplinary non-pharmacological treatment program (including individually prescribed aerobic exercise and cognitive-behavioral therapy) on fibromyalgia symptoms and hypothalamic-pituitary-adrenal (HPA) axis function. Salivary and venous blood samples were collected from 12 female patients with fibromyalgia (age: 25-58) the day before and the day after the treatment period: saliva, eight times (every two hours from 0800 to 2200 h); venous blood, at 0800 h. Peripheral blood mononuclear cells (PBMC) were separated and analyzed for glucocorticoid receptor-alpha (GR-alpha) mRNA expression by semi-quantitative RT-PCR, while the salivary cortisol concentration was determined by RIA. At the same time, pain and aerobic capacity were evaluated. Aerobic capacity improved at the end of the treatment program. The slope of the regression of salivary cortisol values on sampling time was steeper in all patients after treatment, indicating that the cortisol decline was more rapid. Concomitantly, the area under the cortisol curve "with respect to increase" (AUC(i)) was higher and there was a significant increase in GR-alpha mRNA expression in PBMC. The number of positive tender points, present pain, pain area and CES-D score were significantly reduced after the treatment, while the pressure pain threshold increased at most of the tender points. Our findings suggest that one of the active mechanisms underlying the effects of our treatment is an improvement of HPA axis function, consisting in increased resiliency and sensitivity of the stress system probably related to stimulation of GR-alpha synthesis by the components of the treatment.

Reactivity to superficial and deep stimuli in patients with chronic musculoskeletal pain.

In this study, we evaluated pain sensitivity in patients with fibromyalgia or other types of chronic, diffuse musculoskeletal pain to establish whether fibromyalgia represents the end of a continuum of dysfunction in the nociceptive system. One hundred and forty five patients and 22 healthy subjects (HS) completed an epidemiological questionnaire to provide information about fatigue, stiffness, sleep, the intensity of pain (VAS 0-100) and its extent both at onset and at present. Algometry was performed at all American College of Rheumatology (ACR) tender points and at ten control points. Patients were divided into five main groups: fibromyalgia (FS) patients, secondary-concomitant fibromyalgia (SCFS) patients, patients with widespread pain (WP) but not reaching the ACR criterion of 11 tender points, patients with diffuse multiregional pain (MP) not reaching the ACR criteria (widespread pain, tender point counts), and patients with multiregional pain associated with at least 11 tender points (MPTE). von Frey monofilaments were used to assess superficial punctate pressure pain thresholds. Heat and cold pain thresholds were determined with a thermal stimulator. Ischemic pain was assessed by the cold pressure test and the submaximal effort tourniquet test. The scores for stiffness and present pain intensity gradually increased concomitantly with the increase in tender point count and pain extent. The pressure pain thresholds for positive tender and positive control points were significantly lower in the SCFS, FS and MPTE groups than in HS, MP and WP groups, the latter three groups displaying similar values. In all groups, there were no differences in pain thresholds between positive tender and positive control points. The heat pain threshold and the pain threshold in the cold pressure test were lower in the FS and SCFS groups than in HS. The cold pressure tolerance was lower in patients with widespread pain than in HS. In the von Frey test, all patient groups except MP had similar values, which were significantly lower than in HS. Finally, all patient groups displayed lower tourniquet tolerance than HS. In each psychophysical test, patients with widespread pain and patients with multiregional pain showed similar thresholds; however, the thresholds in the MP or MPTE groups differed from those in the FS and SCFS groups. In the FS group, pain thresholds and pain tolerance did not differ according to the presence of ongoing pain at the stimulated site and were not correlated to ongoing pain. The results indicate that dysfunction in the nociceptive system is already present in patients with multiregional pain with a low tender point count; it becomes more and more severe as the positive tender point count and pain extent increase and it is maximal in fibromyalgia patients.

Pain Symptoms in Fibromyalgia Patients with and without Provoked Vulvodynia.

Objective. The aim of the study was to compare the pain symptoms of fibromyalgia patients exhibiting (FMS+PVD) and not exhibiting (FMS) comorbidity with provoked vulvodynia. Study Design. The case control study was performed in 39 patients who had been diagnosed with FMS and accepted to undergo gynaecological examination and in 36 healthy women (C). All patients completed standardized questionnaires for pain intensity, pain area, and psychological functioning. The gynaecological examination included vulvar pain pressure reactivity (Q-tip), pelvic tone assessment (Kegel manoeuver), and a semistructured interview collecting detailed information about pelvic symptoms and sexual function. Results. FMS+PVD patients displayed a higher number of associated symptoms than FMS patients. The vulvar excitability was significantly higher in FMS+PVD than in FMS and in both groups than in Controls. Half of FMS+PVD patients were positive to Kegel manoeuver and displayed higher scores in widespread pain intensity, STAI-Y2, and CESD levels than Kegel negative patients. Conclusions. The study reveals that increased vulvar pain excitability may occur in FMS patients independently of the presence of coital pain. Results suggest that coital pain develops in patients with higher FMS symptoms severity due to the cooperative effects of peripheral and central sensitization mechanisms.

Alexithymia in fibromyalgia syndrome: associations with ongoing pain, experimental pain sensitivity and illness behavior.

OBJECTIVE: Alexithymia, a lack of emotional awareness, is common in chronic pain patients. The aim of the study was to investigate the relationship of alexithymia to ongoing pain, experimental pain sensitivity, and illness behavior in patients with chronic musculoskeletal pain. METHODS: Sixty-eight women with fibromyalgia (age: average, 43.4 years; range, 19-72 years) completed self-report measures on alexithymia (20-Item Toronto Alexithymia Scale), ongoing pain [Visual Analogue Scale, Questionario Italiano del Dolore (QUID), Margolis], psychological distress (Center for Epidemiology Studies-Depression Scale, State-Trait Anxiety Inventory Form Y), and illness behavior (Illness Behavior Questionnaire). Psychophysical tests were performed to assess experimental pain sensitivity, including pain thresholds for mechanical (von Frey, tender point count) and thermal (heat, cold) stimuli, and cold pressor pain threshold and tolerance. RESULTS: Alexithymia "difficulty identifying feelings" (DIF) was related to higher ratings of the affective-but not the sensory-dimensions of ongoing pain (QUID) and to a lower cold pressor pain tolerance, while alexithymia scores were independent of all pain thresholds. Multiple regression demonstrated that alexithymia DIF ceased to uniquely predict affective ongoing pain when psychological distress or illness behavior was separately controlled for. Higher alexithymia DIF scores were predictive of hypochondriacal illness behavior, over and above what was explained by psychological distress and affective pain. CONCLUSION: Alexithymia is associated with increased affective pain and hypochondriacal illness behavior. The former relationship is better explained, and possibly mediated, by psychological distress and illness behavior. The hypothesis of a generally increased sensitivity to unpleasant stimuli in alexithymic chronic pain patients is not supported by the data.

Dimensions of "unidimensional" ratings of pain and emotions in patients with chronic musculoskeletal pain.

The use of unidimensional scales to measure pain intensity has been criticised because of the multidimensional nature of pain. We conducted multiple linear regression analyses to determine which dimensions of pain--sensory versus affective--predicted scores on unidimensional scales measuring pain intensity and emotions in 109 Italian women suffering from chronic, non-malignant musculoskeletal pain. We then compared the results with earlier findings in two groups of cancer patients suffering from acute post-operative pain and chronic cancer-related pain, respectively. Age, physical capacity and scores on the multidimensional affect and pain survey (MAPS) were used to predict patients' ratings on one visual analogue scale (VAS) and three numerical rating scales (NRS) measuring pain intensity, anxiety and depressed mood. Unidimensional pain intensity ratings were predicted better from sensory than from affective pain predictors, and the affective predictors made no unique contribution (NRS), or only a very small one (VAS). Both sensory and emotional pain aspects were unique predictors of NRS anxiety and depression. Therefore, in contrast to earlier findings in two different types of cancer patients, in subjects affected by chronic non-malignant musculoskeletal pain, the scores on unidimensional pain intensity scales mainly reflect sensory pain dimensions, supporting the discriminant validity of the NRS and VAS used. However, the patients had some difficulty in distinguishing between sensory and emotional information. For this reason, several unidimensional scales to rate pain intensity and emotions separately should be used to obtain a complete picture of the status and needs of any given patient.