July 2017
David Craig, PharmD | Editor


The Journal of Pain

Highlights from The Journal of Pain (Volume 18, No. 7, July 2017 Issue)

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Study Highlights Inconsistencies in Fibromyalgia Treatment Guidelines

Kati Thieme, Marc Mathys, Dennis C. Turk; Institute of Medical Psychology at Philipps University Marburg, Marburg, Germany; Institute of Medical Psychology at Philipps University Marburg, Marburg, Germany; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington

Research reported in The Journal of Pain shows inconsistencies in four clinical practice guidelines for the treatment of fibromyalgia patients published by leading medical associations. 

The study reviewed and compared fibromyalgia guidelines published by the American Pain Society (APS) in 2005, the Association of Scientific Medical Societies in Germany in 2012, the Canadian Pain Society (CPS) in 2013, and the European League Against Rheumatism (EULAR) in 2016.  Each guideline used systematic reviews and meta-analyses as the highest level of evidence.  APS, CPS, and AWMF also included results from randomized clinical trials.   

Fibromyalgia can be difficult and time-consuming to diagnose, and the etiopathology of this condition is unknown. Absences of definitive treatment have led to physician prescribing of a wide variety of pharmacological and non-pharmacological therapies. Despite the range of treatments, outcomes are modest. Inconsistency in treatment results was the primary impetus for the development of clinical practice guidelines to help doctors and patients determine possible treatment options.

Guidelines developed by APS, CPS, and AWMF assigned the highest ranking of recommendation to aerobic exercise, cognitive-behavioral therapy, amitriptyline, and multicomponent treatment. The EULAR guideline, however, assigned its highest recommendation to exercise, representing a change from its 2008 guideline, which recommended pharmacotherapy. 

The authors noted that inconsistencies across the guidelines are attributed to criteria used for study inclusion, study results, weighting systems, and panel membership.  They concluded that a guideline consensus meeting would be useful to reduce inconsistencies and synthesize guidelines to help improve treatment for fibromyalgia patients.

Clinician-Patient Relationship Can Influence Pain Experience

Elizabeth A. Reynolds Losin, Steven R. Anderson, Tor D. Wagner; Department of Psychology, University of Miami, Cox Neuroscience Annex, Coral Gables, Florida; Institute of Cognitive Science, University of Colorado Boulder, Boulder, Colorado

It is widely known that pain is highly subjective and modifiable by factors other than treating external sources of tissue damage.  An understudied concept is the impact of the physician-patient relationship on pain.  Researchers from the University of Miami and University of Colorado examined the hypothesis that the clinician-patient relationship can modulate pain experienced in medical care. 

For the study, researchers measured feelings of perceived clinician-patient similarity and trust to determine if these interpersonal factors influenced pain.  Previous studies have shown that patients report higher satisfaction with clinicians who share their race, gender, and language.  Eighty participants were divided into two groups on the basis of their responses to questions about personal beliefs and values.  Painful stimulation was used to mimic pain from a medical procedure. 

Consistent with the hypothesis, results showed that patients’ positive feelings of similarity and trust toward their clinicians—but not clinicians’ feeling toward patients—predicted lower pain intensity ratings by patients in response to painful thermal stimulations. The higher patients rated their feelings of similarity and trust toward their clinicians, the lower they rated their pain intensity. The study also showed that the most anxious patients exhibited the strongest relationship between their feelings about clinicians and their reported pain intensity.

The researchers noted that simply increasing patients’ feelings of similarity and trust toward their clinician may decrease perceived pain independent of any systematic manipulation of the clinician’s behavior.

The authors concluded that their findings suggest that teaching clinicians new ways to find common ground with their patients might be an effective way to reduce pain and pain-related disparities without necessitating changes to the demographic characteristics of the clinician workforce. Interventions aimed at increasing patients’ feelings of similarity to and trust in healthcare providers may help reduce pain experienced during medical care.


Highlights from PAIN (Volume 158, No. 7, July 2017 Issue)

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The Pain Course: A Randomised Controlled Trial Comparing a Remote-Delivered Chronic Pain Management Program When Provided in Online and Workbook Formats

B. F. Dear, M. Gandy, E. Karin, T. Ricciardi, V. J. Fogliati, S. McDonald, L. G. Staples, K. Nicholson Perry, L. Sharpe, M. K. Nicholas, N. Titov; CentreClinic, Department of Psychology, Macquarie University, Sydney, Australia; Australian College of Applied Psychology, Sydney; Department of Psychology, University of Sydney, Sydney; Pain Management Research Institute, Northern Clinical School, Kolling Institute of Medical Research, University of Sydney, Sydney

Several approaches have been used to increase access to evidence-based information and pain management programs in recent years. Numerous websites now provide information and recommendations to people with chronic pain. Internet-delivered programs use the same principles and content as traditional programs but are provided remotely without the need for clinicians and patients to meet face to face. This study compared the efficacy and acceptability of a validated internet-delivered pain management program, the Pain Course, when delivered in workbook and online formats.

After a brief telephone screening assessment, 178 participants were randomized to 1 of 2 groups: the Internet-delivered pain management group or the workbook-delivered pain management group. It was hypothesized that significant improvements in levels of disability, depression, anxiety, and average pain would be observed consistent with previous trials and that no clinically meaningful differences would be observed between the 2 groups immediately posttreatment, at 3-month follow-up, or at 12-month follow-up. It also was hypothesized that both treatments would be associated with high levels of acceptability and treatment completion.

Findings suggest that the workbook format was no less effective or acceptable than the validated online format. Both groups reported significant improvements across the primary outcomes of disability, anxiety, and depression immediately posttreatment. Further improvements were observed in disability levels to 3-month follow-up, and improvements across other primary outcomes were maintained until 12-month follow-up. Significant improvements also were observed in average pain levels, and a range of the other important psychological variables often were targeted in pain management programs. Treatment completion rates and satisfaction levels also were high, and relatively less clinician time was needed to support participants through the program in either format.

This study highlights the potential for use of evidence-based hard copy workbooks as a “low tech” alternative to increase access to pain management programs alongside rapidly e-merging Internet-delivered pain management programs.

The Clinical Journal of Pain

Highlights from The Clinical Journal of Pain (Volume 33, No. 7, July 2017 Issue)


Chronic Pain and Itch Are Common Morbid Sequelae Among Individuals Who Receive Tissue Autograft After Major Thermal Burn Injury

Matthew C. Mauck, Jennifer Smith, Andrea Y. Liu, Samuel W. Jones, Jeffrey W. Shupp, Marie A. Villard, Felicia Williams, James Hwang, Rachel Karlnoski, David J. Smith, Bruce A. Cairns, Ronald C. Kessler, and Samuel A. McLean; TRYUMPH Research Program; Departments of Anesthesiology, Emergency Medicine, and the Jaycee Burn Center, University of North Carolina, Chapel Hill; The Burn Center, MedStar Washington Hospital Center, Washington, DC; Department of Surgery, University of South Florida, Tampa; Department of Health Care Policy, Harvard Medical School, Boston

Most hospitalized patients who sustain burns receive an autologous skin graft (autograft) in which skin (epidermis and part of the dermis) is removed from a healthy “donor” site and transplanted to a burn site. Evidence suggests that pain and itch symptoms are common among burn survivors and can result in suffering over time. This study evaluated pain and itch symptom characteristics among patients treated with a tissue autograft after major thermal burn injury (MThBI), from the time of initial burn center admission through one year. Investigators hypothesized that pain and itch at both the donor and graft sites would be common, but that autograft site pain and itch would be more severe and long lasting. They also hypothesized that burn pain and itch symptoms would be increasingly associated over time and that both pain and itch would be associated with clinically significant reductions in physical and mental health functioning.

Study results suggested that moderate or severe pain is nearly universal in the immediate aftermath of MThBI, and that while persistent donor-site symptoms are rare, persistent moderate or severe graft pain and/or itch occur in a substantial subset of individuals and are associated with clinically significant reductions in physical and mental health. Although there is little correlation between pain and itch symptom severity during the early aftermath of MThBI, the strength of association increases over time and becomes moderate to strong after 3 months. During the months after MThBI, pain and itch symptoms also are associated with increasing temporal association.

A lower burden of pain versus itch was associated with clinically significant interference with role-specific function, suggesting that burn survivors with persistent moderate or severe pain experience significant pain-related interference with function, whereas burn survivors with severe itch experience significant itch-related interference with function.

These epidemiologic data provide evidence that pain and itch in burn survivors share overlapping pathways/mechanisms, a hypothesis that is supported by increasing preclinical data. Further work is needed to understand specific mechanisms mediating chronic pain and itch after MThBI. This work is essential to develop new treatments to reduce the tremendous burden of suffering and decline in physical and mental health caused by chronic pain and itch among survivors of MThBI.

Impaired Pain Modulation in Fibromyalgia Patients in Response to Social Distress Manipulation

Rita Canaipa, Alexandre Castro-Caldas, João Manuel Moreira, Fernando Pimentel-Santos, Jaime Cunha Branco, and Roi Treister; Faculty of Medicine and Faculty of Psychology, University of Lisbon, Health Science Institute, Portuguese Catholic University, Portuguesa; Rheumatology Department, CEDOC, NOVA Medical School, Faculty of Medical Sciences, NOVA University of Lisbon, CHLO; Hospital Egas Moniz, Lisboa, Protugal; and Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel

Pain modulation can be triggered peripherally (for example, “pain inhibit pain” or conditioned pain modulation) or centrally (cognitive or emotional manipulations). Cumulative evidence has shown abnormal pain modulation in patients with fibromyalgia (FM). Also, deficits in pain modulation seem to be influenced by emotional manipulation among these patients. Social distress has been described as a real-life situation that can modulate physiological and behavioral pain-related responses in laboratory settings. It has been mostly studied using Cyberball, a paradigm based on a virtual ball-tossing game, during which participants “play” with other real participants. In fact, they are playing with a preprogrammed computer that enrolls the participant into a condition in which he or she is socially included (inclusion condition) or excluded from the game (exclusion condition).

In healthy individuals, the impact of social exclusion induced by Cyberball is associated with increased sensitivity to pain. At the clinical level, deficits in social relationships are well documented with evidence of increased loneliness compared with rheumatoid arthritis (RA) and other pain rheumatic conditions, which in turn are associated with increased pain. This study investigated the modulatory role of social distress in pain sensitivity among patients with FM, RA, and pain-free controls (PFC). The effect of Cyberball manipulation on pain and unpleasantness as measured in response to phasic (electrical) and tonic (cold) noxious stimuli was assessed. Investigators hypothesized that people with FM would demonstrate altered pain inhibition under social manipulation when compared with control groups.

The hypothesis that patients with FM will differently modulate pain in response to social distress manipulation was partially confirmed: In contrast to patients with RA and PFC, patients with FM demonstrated increased pain and unpleasantness in response to electrical stimulation in the inclusion condition. The primary finding was that in FM, pain induced by electrical stimulation was increased by social inclusion, suggesting altered pain modulation in response to inclusion. Only electrical pain, but not cold pain, was affected by the Cyberball manipulation.

The correlations found in PFC between pain sensitivity at baseline and sensitivity to social distress implies that those who are more sensitive to pain are also more susceptible to social distress. Future psychological interventions for patients with FM might be improved with interventions designed to improve positive emotional and social processing.

Study Highlights Inconsistencies in Fibromyalgia Treatment Guidelines