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 o Pain o Fatigue Figure 1 Central sensitisation and CWP o Activity limitations

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

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

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

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 Rheumatol 2: 416–424 doi:10.1038/ncprheum0245

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

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

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

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