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Chronic Widespread Pain (3.9.1 - 3.9.9)

Updated: Mar 7, 2022




3.9.1 Discuss cultural and social influences on the evolution and understanding of

the following pain conditions:


“Railway spine”

It was a 19th century diagnosis for post-traumatic symptoms of passengers involved in railroad accidents

People came forward stating they had ailments - however there was no obvious injury so these injuries were regarded as fake


Reference:


“Writers’ cramp” or Focal Hand dystonia

Description

Idiopathic movement disorder of adult onset characterised by abnormal posturing and movement of the hand and/or forearm during tasks requiring skilled hand use such as writing.


Epidemiology

Typical age onset 30-50yo


Presentation

Often a feeling of tension in the fingers and forearms that interferes with writing fluency

It can progress to significant muscle pain and cramping from minimal exertions such as turning pages of a book. Can cause other symptoms such as uncomfortable positioning similar to restless legs syndrome, trembling in the jaw, TMD, voice problems.

EMGs placed into the muscles effected can show nerve signals transmitted even when the limbs are at rest

Symptoms can vary significantly over time

Can see mirror effects - use of one hand causes worsening of symptoms in other limbs.

Stress, anxiety, lack of sleep, sustained use, and cold temps can worsen symptoms


Cause

Not known. Excessive fine motor activity likely plays a role

There may be a genetic component - up to 20% of patients have a family member with similar


Management

Quite difficult due to no understanding of underlying pathophysiology

Botox can be helpful in some cases

Behavioural retraining with writing devices, switching hands, occupational therapy, biofeedback, etc. None are effective in all cases.

Anticholinergics have been tried with some success


Reference:


Myofascial pain syndrome


Definition

Defined as pain from myofascial trigger points in skeletal muscle

Thought to be regional pain from hyper irritable spots in taut bands of skeletal muscle known as myofascial trigger points


Causes

  • Direct or indirect trauma

  • Spine pathology

  • Exposure to cumulative or repetitive strain

  • Postural dysfunction

  • Physical reconditioning

Diagnostic criteria

There is none. Some electrodiagnostic and morphologic findings have been seen but are not clinically practical

Basically - first 3 are essential:

  • Taut band in muscle

  • Exquisite tenderness at a point on the taut band

  • Reproduction of the patient's pain

  • Local twitch response

  • Referred pain

  • Weakness

  • Restrictive ROM

  • Autonomic changes

Presentation

Acute or chronic muscle pain

Dull, deep, aching and poorly localised pain

Stabbing is rare

Can have some somatic referred pain


DDx

  • Hypothyroidism

  • Iron deficiency

  • Vitamin D insufficiency

  • Vitamin B12 deficiency

  • Parasitic infection

Treatment

  • NSAIDs - No RCTs looking at NSAIDs in MPS (may consider use but risks+)

  • Tramadol - No studies

  • Opioids - No evidence - possible evidence of harm

  • Lidocaine patch - Few small RCTs showed some benefit over placebo

  • Benzodiazepines - No RCTs

  • Gabapentinoids - No RCTs

  • TCAs - None

  • SNRI - None

  • Botox - Double blind RCT suggested benefit at 4 weeks. Cochrane study with mixed benefit


Dry needling - Hart to do RCTs. Dry needling test was done in anaesthetised patients - superiority of dry needling versus placebo.


Reference:

Desai, M. J., Saini, V., & Saini, S. (2013). Myofascial pain syndrome: a treatment review. Pain and therapy, 2(1), 21–36. https://doi.org/10.1007/s40122-013-0006-y


Fibromyalgia syndrome


Definition

The most common cause of chronic widespread musculoskeletal pain

Often associated with fatigue, cognitive disturbance, psychiatric symptoms and multiple somatic symptoms


Epidemiology

Most common in women 20-55 yo

2-3 % prevalence and increases with age

Possibly more prevalent and varies with diagnostic criteria


Presentation

Generalised pain, fatigue, sleep disturbances - lasting for at least 3 months not explained by any other medical condition


Pain is now described as 'multisite pain' following a working group in 2018. Typically pain involves six different sites. Can be muscles and joints.


Fatigue and sleep are core features of the diagnosis. Often stiff in the morning and feel unrefreshed. Often they say they sleep 'lightly' waking frequently during the early morning and difficulty getting back to sleep


'Fibro fog' is common. Difficulties with attention and doing tasks requiring rapid thought changes. Meta-analysis of 23 case-control studies found significant impairment in FM patients compared to controls - explained in part by pain and depression.


Psychiatric symptoms are common - 30-50% at diagnosis also have depression and/or anxiety. FM patients are three times more likely to also have depression than others. 1/4th of patients with FM had major depression and 1/2 had a history of depression.


Headaches are common in 50% of patients with FM including migraine and muscular tension types.


Paraesthesias - Are common but electrophysiologic testing is normal


Comorbid conditions are often found including abdominal, chest wall pain, IBS, pelvic pain etc.


Physical findings

Often marked tenderness on modest palpation in multiple soft tissue sites

Rarely there may also be signs of small-fibre neuropathy


Diagnosis

Chronic pain of at least 3 months duration without another cause. Widespread pain at multiple sites with moderate to severe problems with sleep or fatigue. Widespread tenderness in exam may be found and there is an absence of joint swelling or other evidence of inflammatory changes on physical examination


The American College of Rheumatology diagnostic criteria for 2010 and related documented sheets can be useful. Tender points that were a critical feature in the 1990 diagnostic criteria are no longer required.


2010 diagnostic criteria assess:

  • Widespread pain index > 7 and symptom severity scale >5

  • WPI 4-6 and SSS >9

  • Symptoms present for 3 months

  • No other disorder explains symptoms

2011 changes altered criteria slightly to allow for patients to self-administer the questions.


2016 multisite pain was suggested - pain in 4 of 5 regions


There is also an ACTTION-APS Pain taxonomy AAPT - which tried to define criteria more clearly in 2019. These criteria are:

  • MSP defined as six or more pain sites from a possible nine

  • Moderate to severe sleep problems or fatigue

  • Both must have been present for at least 3 months

Pathophysiology of Fibromyalgia

  • Temporal summation of pain

  • Decreased endogenous pain inhibition - endogenous opioid responsiveness changes

  • Neuropeptide changes - particularly with upregulation of pronociceptive peptides such as substance P.

  • Brain pain dysregulation - morphology, neurotransmitter, and resting-state connectivity changes

  • Loss of descending inhibition

  • Altered HPA axis changes

  • Genetic predisposition

  • Decreased grey matter volume

Differential diagnosis



Investigations

CBC + and ESR or CRP can be used. Further testing does not really help. ANA and RF are rarely helpful. CK or TSH also are options.


Treatment

Initial management


Patient education - 2019 Systematic review level 1A - suggested patient education reduced pain intensity, anxiety (as well as catastrophising) and should be the first step for fibromyalgia

  • Fibromyalgia is a real illness

  • Explain centralised pain

  • Lack of evidence of persistent infection or damage

  • Stress and mood disorders role

  • Sleep and sleep hygiene

  • Importance of exercise - address the muscle 'spasm' pain and 'deficient blood flow'

  • Prognosis - likely symptoms will wax and wane

Addressing comorbidities

  • Sleep

  • Mood disturbances

  • IBS

Exercise - Evidence from RCTs and Systematic reviews. 2017 Systematic review - exercise improves health-related quality of life and low-quality evidence that aerobic exercise decreases pain and improves physical function

  • Low-impact aerobic exercise for patients with fibromyalgia. Benefits for pain, function and may be benefits for sleep. Even modest exercise can help.

  • Preferences based on patient interest are key

  • Ideally 30 mins of aerobic exercise 3 times per week

CBT



Pharmacology

TCA at night time at 10 mg - 2015 review of systematic reviews and meta-analyses supported the view that low dose amitriptyline is first line.


SNRI (particularly if fatigue or depression is a major feature). 2013 systematic review and meta-analysis involving 6000+ patients showed duloxetine superior to placebo in pain reduction in FM


Gabapentinoids (particularly if sleep problems) - 2018 summary of clinical trials, open-label extensions, meta-analyses and post-hoc analyses for pregabalin in FM confirmed improved pain, sleep, and overall patient status in a wide range of demographics.


For example, the average ‘number needed to treat’ for achieving a 50% reduction in pain in one patient is 4 for amitriptylin, 8 for duloxetine and 14 for pregabalin (Lunn, Hughes, & Wiffen, 2014; Moore, Derry, Aldington, Cole, & Wiffen, 2015; Wiffen et al., 2013)


In real world use, most patients do not use appropriate dose or for appropriate duration


Prognosis

Most have long term pain and fatigue sadly

Meta-analysis in 2012 suggested few patients gain signfiicant benefit from pharmacological therapies

There may be an increased risk of suicide in the cohort


Reference:

UpToDate Accessed July 2021


Whiplash

Definition

Characterised by sudden acceleration-deceleration movements of the head with flexion and extension of the neck - causing injury to the cervical spine


Epidemiology

300-600 per 100,000 in North America and Western Europe

79% of whiplash patients reported residual pain 12 months after their accident

40-50% often have chronic symptoms


Diagnosis and classification

Quebec Task Force Classification of Grades of Whiplash Associated Disorders



Presentation

Important to make sure she is medically cleared (e.g. imaging as appropriate via the Canadian C-spine criteria.

Once stable, a full history of the event including possible risks for PTSD (the impact of events scale) and catastrophisation should be assessed. If found, psychological factors should be addressed early





Prognostication

  • Baseline neck pain intensity and disability are strongly correlated with outcome

  • Post-injury anxiety

  • Catastrophising

  • Compensation and legal factors

  • Early use of healthcare

  • Initial neck ROM and cold hyperalgesia are predictive of ongoing disability


  • Trauma-related parameters have NO effect on outcome

  • MRI findings had no bearing on outcome

  • Collision factors also had no bearing

  • Age, gender, marital status and education are NOT predictive of ongoing disability

  • Previous physical health is NOT predictive of ongoing pain/disability

  • COMPENSATION factors are inconclusive



Management

Advise patients to stay active

Reassure that they should do normal activites

Exercise is beneficial including neck exercises

Acute pain medications include:

  • Paracetamol,

  • NSAIDs (if paracetamol is ineffective),

  • Opioid analgesics ONLY in very short use if at all (WAD grades > 2-3 only)

Acupuncture is ineffective

Kinesio taping, manual therapy and manipulation, trigger point needling, surgery, have minimal evidence or role


There may be roles for repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (TDCS). Meta-analysis in 2016 showed positive results in fibromyalgia.


Reference:

Al-Khazali, Haidar Muhsena; Ashina, Håkana; Iljazi, Afrima; Lipton, Richard B.b; Ashina, Messouda; Ashina, Saitc; Schytz, Henrik W.a,* Neck pain and headache after whiplash injury: a systematic review and meta-analysis, PAIN: May 2020 - Volume 161 - Issue 5 - p 880-888

doi: 10.1097/j.pain.0000000000001805


Hou, W. H., Wang, T. Y., & Kang, J. H. (2016). The effects of add-on non-invasive brain stimulation in fibromyalgia: a meta-analysis and meta-regression of randomized controlled trials. Rheumatology (Oxford, England), 55(8), 1507–1517. https://doi.org/10.1093/rheumatology/kew205


FND



Somatic Symptom Disorder

(SEE BELOW)

 

3.9.2 Understand the differences between symptom cluster, syndrome and metasyndrome, with particular reference to chronic widespread pain.


Symptom Cluster: 2 or more symptoms that are related to each other and that occur together. Symptom clusters are composed of stable groups of symptoms, are relatively independent of other clusters, and may reveal underlying dimensions of symptoms


Syndrome: a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms.


Metasyndrome: - Cannot find this definition within Google (somatoform behaviours etc.)

 

3.9.3 Outline the heterogeneity of the clinical phenotype of “chronic widespread

pain”.


Diagnostic clarification of chronic widespread pain has been historically difficult. For example, in ICD-10 pain is attributable exclusively to an underlying pathophysiological mechanism. If that mechanism has not been clearly elucidated, then the only options for diagnosis are somatoform pain disorders.


However, there are clearly disorders for which there is pathophysiological factors ongoing with contributing biological, social, and psychological factors, contribute - which currently do not have a diagnostic basis.


Chronic primary pain overcomes these limitations by providing a clear definition without inappropriate classification into psychiatric disorders and allows for subtypes.


Arguably, simply defining chronic pain into 'somatic' or 'psychogenic' has become obsolete


Terms like 'functional' never made clear sense in regards to its dichotomous understanding of either it's 'all in the head' or are we talking about a persons level of function?!


Chronic primary pain definition:

- Persists for longer than 3 months

- Is associated with significant emotional distress (e.g. anxiety, anger, frustration) and/or significant functional disability (interference in ADLs and social roles)

- Symptoms are not better accounted for by another diagnosis


Chronic primary pain can occur in any body system, and in anybody site including a combination of sites.



Chronic widespread pain is diffuse musculoskeletal pain in at least 4 of 5 body regions and in at least 3 or more body quadrants (upper-lower/left-right) and axial skeleton

It is associated with significant distress and/or functional disability


The diagnosis is appropriate if pain is NOT directly attributable to nociceptive pain in these areas and if there are features consistent with nociplastic pain such as spontaneous or evoked pain in the region with allodynia and/or hyperalgesia with psychological and social contributors.


Fibromyalgia syndrome - is itself a FORM of CWP - in at least 4 of 5 body regions and is associated with sleep disorders, cognitive dysfunction, and somatic symptoms. Symptoms need to be present for 3 months and not explained by something else.


Reference: IASP - Chronic primary pain discussion paper (2018)

 

3.9.4 Compare and contrast neurobiological and psychobiological understandings

of chronic widespread pain, including but not limited to:


Central sensitisation of nociception

  • Central sensitisation is a neuronal signal amplification process leading to a greater perception of pain

  • Fibromyalgia, and related conditions, are thought to be related to a pain-processing problem within the brain leading to hypersensitivity to painful stimuli.

  • Mono-aminergic neurotransmission is disrupted with elevated excitatory neurotransmitters (glutamate and substance P) and fewer neurotransmitters such as serotonin and norepinephrine involved in descending anti-nociceptive pathways.

  • Dopamine dysregulation and endogenous opioid alterations likely explain the central pathophysiology of FM

  • Psychological factors can exacerbate sensitisation - for example 'cognitive-emotional sensitisation' describes where a patient pays more attention to their pain, it can increase their perception of pain

  • Bidirectional relationship with neurotransmitter changes

Evidence for these changes has been noted in fMRI studies where the same amount of pressure leads to greater neuronal activation of pain-processing areas of the brain in patients with FM compared with controls.


Reference:

Siracusa, R., Paola, R. D., Cuzzocrea, S., & Impellizzeri, D. (2021). Fibromyalgia: Pathogenesis, Mechanisms, Diagnosis and Treatment Options Update. International Journal of Molecular Sciences, 22(8), 3891.


Affective spectrum disorders

These are the large array of different mood disorders.

There is an increasing suggestion of genetic and environmental factors predisposing a patient to affective disorders - in a similar way to pain disorders

These are often also disorders of neurotransmitter regulation and these are similar processes as in pain conditions

It is likely the acute stress response - with its associated HPA system alterations play a role in disrupting normal neurotransmitter use

 

3.9.5 Critically discuss “fibromyalgia syndrome” as an example of:


(a) chronic primary pain (as a taxonomic entity)

See above in detail


(b) Nociplastic pain (as an example of this descriptor of mechanism)


Nociplastic pain is pain that results from dysfunction of the somatosensory nervous system despite mostly intact neural and non-neural structures


Both chronic primary pain and functional pain disorders are dominated by 'nociplastic pain'.

'Functional' implies multifactorial etiologies

'Primary' suggests unknown or absent contributors and can imply fewer preventative and treatment options


Reference:

Popkirov, S., Enax-Krumova, E. K., Mainka, T., Hoheisel, M., & Hausteiner-Wiehle, C. (2020). Functional pain disorders - more than nociplastic pain. NeuroRehabilitation (Reading, Mass.), 47(3), 343–.


Popkirov, Stoyan et al. ‘Functional Pain Disorders – More Than Nociplastic Pain’. 1 Jan. 2020 : 343 – 353.


(c) central sensitisation of nociception (as an example of a pathophysiological process)

Discussed above

Pain processing is from structures (nociceptors over spinal wide dynamic range neurons to a mesolimbic network), functions (extinction, inhibition, habituation to conditioning, amplification and sensitisation) to directions (bottom-up, top-down, immune and endocrine systems, organisms and their external environments)


(d) an affective symptom disorder (as a psychological construct)

Discussed above


(e) a syndrome (as a clinical entity)

 

3.9.6 Discuss the evolution of the concept of somatic symptom disorder


SSD is a single diagnostic entity that replaces 3 of the DSM4 somatoform disorders (somatisation disorder, pain disorder, and undifferentiated somatoform disorder (and in some cases, hypochondriasis))


Diagnosis of SSD requires:

  • 1 or more physical symptoms lasting 6 months or longer associated with excessive thoughts, feelings or behaviours

  • It is described in terms of: Nature (e.g. pain), duration (persist and severity)

Described in words - Disproportionate emotional distress and excessive, unsatisfactory, and maladaptive illness and sick-role behaviours. The ultimate source of the somatic symptoms is less important than the patient's reaction to the symptoms.


SSD is the evolution from DSM 4 where diagnoses like 'pain disorder' were criticised.

  • The questionable importance of medically unexplained pain in pain disorder associated with psychological factors

  • Lack of a definition of psychological factors or a description of when they are of sufficient importance or magnitude to play a role in the pain experienced in the presence of a general medical condition - made it a diagnosis of exclusion

Criticisms of DSM5 SSD include:

  • Diagnostic inflation with fear of misdiagnosing a medical illness (false positive rate is likely also to be high and 15% of cancer patients, 15% of heart disease patients and 25% of IBS would qualify for a diagnosis of SSD) - However, seems somatic symptom disorder may be more restrictive than previous 'somatisation' diagnosis

  • Inadequate field testing

Risks with new SSD category include:

  • Stigma

  • Overlooked diagnoses with a failure to investigate new or worsening symptoms

  • Increased risk of inappropriate psychotropic medications

  • Gender trap - women present with physical symptoms more commonly than men

Working group suggested benefits:

  • Construct (appropriateness of the inferences made from), descriptive (accuracy and objectivity of information gathered) and predictive (Extent to which a score or test predicts scores on some criterion measure or future outcome) validity were improved

  • Inter-rater reliability

  • Test-retest reliability are good to very good

  • May actually reduce overdiagnosis - they require more functional difficulties such as emotional, thoughts or behaviours, than the previous 'somatoform disorders'

  • Removing 'medically unexplained' symptoms is important as it was very unreliable. It is difficult to prove that a symptom is 'negative' based upon investigations and clinical acumen.


 

3.9.7 Discuss the DSM-5 diagnostic category of somatic symptom and related

disorders, including but not limited to:


Somatic symptom disorder

Cochrane review in 2015 looking at 26 RCTs suggested evidence for pharmacological therapy for somatoform disorders is poor with the efficacy of many however these were small sample sizes with a high risk of bias and lack of clear follow-up


Cochrane review in 2014 looked at non-pharmacological therapies for somatisation and CBT, mindfulness, psychodynamic and integrative therapy were superior to usual care or waiting list in reduction of symptom severity. But again these were limited studies.


Epidemiology

  • General population 4-6%

  • Primary care patient - 17%

  • Likely higher in those with other functional disorders such as fibromyalgia (25-60%)

  • Health care utilisation is higher in SSD patients

Risk factors

  • Female sex

  • Fewer years of education

  • Lower socioeconomic status

  • History of childhood chronic illness

  • History of sexual abuse or other childhood or adult trauma

  • Concurrent general medical disorders (especially in older patients)

  • Health anxiety

  • Concurrent psychiatric disorder (especially depression or anxiety disorders)

  • Family history of chronic illness

Underlying factors explained

Developmental factors - poor emotion and high negative emotions lead to symptoms in childhood and these often pervade into adulthood. Particularly if another family member was unwell. Negative parenting and poor attachment may lead to care-seeking behaviours


Physical/sexual abuse - Meta-analysis of 23 studies (4600 patients) examined the association between history of abuse or rape and lifetime diagnosis of somatic syndromes - Somatic symptoms were three times more common in those who had experienced trauma


Cognitive and perceptual distortions and behavioural abnormalities - Some people relate benign sensations to threatening pain and misattribute these to serious disease


Difficulties with self-expression - Physical symptoms can be used to express distress in patients who have difficulty explaining emotions in words (alexithymia).


Clinical presentation

One or more current somatic symptoms that are long-standing and cause distress or psychological impairment. Multiple symptoms can be present but only one is required to make the diagnosis.

Excessive thoughts, worrying, or behaviours related to the somatic symptoms or to health concerns

Can be mild to severe.


The most common symptom is pain


The amount of symptoms is not a factor in making the diagnosis - but the more symptoms the more likely the diagnosis is correct and the more pervasive the condition


REMEMBER this can occur whether the person has a disease or not. The important question is are the persons responses to these somatic symptoms the same or greater than others with the same symptoms?


Prognosis

Sadly most patients become frustrated with their care and care providers.

Clinicians may also experience negative feelings due to their efforts seeming futile

Symptoms fluctuate over time. Improvement can be seen in up to 50% of patients.


Children

Kids can also get this condition. Most common symptoms are abdominal pain, back pain, blurry vision, fatigue, headache, and nausea


Culture

Does not seem to impact prevalence though may influence many other aspects of care


Illness anxiety disorder


Physical complaints are mild or non-existent but lead to excessive worry


Conversion disorder (changed to functional neurological symptom disorder)

DSM5 involves:

  1. One or more symptoms of altered voluntary motor or sensory function

  2. Clinical findings suggesting incompatibility between the symptoms and recognised medical and neurological conditions

  3. These symptoms or signs are not better explained by another medical or mental health disorder

  4. The symptoms cause clinically significant distress in social, occupational, or other areas of functioning that warrant attention

NB: Symptoms are not consciously designed to fill others such as in factious disorder or malingering - but rather are emotional distress not under conscious awareness or control


Epidemiology is not known


History taking

IMportant to ask about symptoms in all facets - Pain, fatigue, sleep, memory and concentration

A history of depression and anxiety is common in these groups

Functional conditions such as irritable bowel syndrome, fibromyalgia, chronic pelvic pain and multiple chemical sensitivity also have strong associations with CD

Examination findings may include Hoover's sign, vibratory sense on the sternum and forehead, and elbow flex-ex test (asked to flex or extend the normal side while the other side is examined at the same time


Investigations can be performed as prudent for risk factors, age etc.


PHQ 15 can be used as a questionnaire - Patient Health Questionnaire


Treatment

Comprehensive and multidisciplinary is the best way

Inpatient therapy has greater evidence than outpatient

CBT has some support and hypnosis has mixed outcomes

Transmagnetic stimulation may have some increasing evidence of benefit - though small studies


Reference:

Tsui, P., Deptula, A., & Yuan, D. Y. (2017). Conversion disorder, functional neurological symptom disorder, and chronic pain: comorbidity, assessment, and treatment. Current pain and headache reports, 21(6), 1-10.


Psychological factors affecting other medical conditions


Factitious disorder

the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives’.

Although rare, in areas of litigation and disability evaluation malingering may be as high as 30%.

 

3.9.8 Demonstrate application of formulation required in patients with chronic

widespread pain.


Formulation is similar to other chronic pain syndromes. No specific evidence or suggestion found in this setting

 

3.9.9 Discuss the unique role of the SPMP in understanding, explaining and

managing chronic widespread pain to patients, their families and colleagues


Provision of chronic pain education, particularly in the setting of CWP, has been shown to lead to lower perceived pain and higher expectations of recovery. These findings are particularly in patients who reported a shift in their pain cognition or self-management strategies.


Younger people have higher expectation of recovery than older. Up to 40% of patients who experience pain education in one study reported no change in their pain cognition nor self-management strategies.

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