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Pain in patients with chronic fatigue syndrome: time for specific pain treatment? (Nijs et al, 2012)

Dolphin

Senior Member
Messages
17,567
Free full text: http://www.painphysicianjournal.com/2012/september/2012;15;E677-E686.pdf


Pain in patients with chronic fatigue syndrome: time for specific pain treatment?

Pain Physician. 2012 Sep;15(5):E677-86.

Nijs J, Crombez G, Meeus M, Knoop H, Damme SV, Cauwenbergh V, Bleijenberg G.

Chronic Pain and Chronic Fatigue Research Group (CHROPIVER), Department of Human Physiology, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussels, Belgium.

Abstract*

BACKGROUND:
Besides chronic fatigue, patients with chronic fatigue syndrome (CFS) have debilitating widespread pain.

Yet pain from CFS is often ignored by clinicians and researchers.

OBJECTIVES:
To examine whether pain is a unique feature of CFS, or does it share the same underlying mechanisms as other CFS symptoms?

Second, it is examined whether effective treatments for pain from CFS are currently available.

STUDY DESIGN:
Narrative review covering the scientific literature up through December 2011.

SETTING:
Several universities.

RESULTS:
From the available literature, it is concluded that musculoskeletal factors are unlikely to account for pain from CFS.

Pain seems to be one out of many symptoms related to central sensitization from CFS.

This idea is supported by the findings of generalized hyperalgesia (including widespread increased responsiveness to painful stimuli) and dysfunctional endogenous analgesia in response to noxious thermal stimuli.

Pain catastrophizing and depression partly account for pain from CFS.

Pain increases during exercise is probably due to the lack of endogenous analgesia and activation of several genes in response to exercise in CFS.

There is currently no evidence in support for the efficacy of complementary medicine in the treatment of pain from CFS.

Intensive education about the biology of pain from CFS (within the framework of central sensitization) has positive short-term effects for patients with CFS, and fatigue-targeting cognitive behavioral therapy appears to be effective for pain from CFS as well.

LIMITATIONS:
The role of the deficient hypothalamus-pituitary-adrenal axis in relation to pain from CFS, as well as the interactions with immune (dys)functioning require further study.

CONCLUSION:
Recent research has increased our understanding of pain from CFS, including its treatment.

It is advocated to optimize current CFS treatment protocols by targeting the underlying mechanism for those patients having severe pain.

PMID: 22996861 [PubMed - in process]
I've given each sentence its own paragraph
 

Dolphin

Senior Member
Messages
17,567
I think it'd be good if one or more letters went in on this one. Here are the guidelines:
http://www.painphysicianjournal.com/2009;12;1-7.pdf


Information for Authors

[..]

Letters to the Editor
Pain Physician publishes letters
to the editor to balance different
points of view, which may offer criticism
of published material. However,
a letter must be objective, constructive,
and educational, and should
clearly state its purpose. Letters to
the editor should not exceed 1,000
words and may include references
(10), tables (2), and figures (2).
1000 words is more generous than most guidelines. I have used more than 10 references in some letters before. However, many only say five. So this gives more scope for more detailed responses than many journals.

The impact factor is high: 10.722 (ref: http://www.painphysicianjournal.com/ ). The BMJ has an impact factor of 13.66 and the Lancet, 30.76, but the impact factor for most journals is in single figures.
 

taniaaust1

Senior Member
Messages
13,054
Location
Sth Australia
Im very good they are looking at other symptoms rather then just fatigue but the following part did bother me

Pain catastrophizing and depression partly account for pain from CFS.

sighs.. so we are seen as catastrophizing our pain. When will the medical profession get that rather we are often down playing the pain not catastrophizing it. Focusing on pain dont help most of us, most of us are aware that focusing on the negatives will make us iller (not just in increasing the pain), so its something most of us try to avoid doing esp when we have so many other symptoms which are concerning us.
 

Dolphin

Senior Member
Messages
17,567
In the abstract it says:
fatigue-targeting cognitive behavioral therapy appears to be effective for pain from CFS as well.
It turns out this is based on one RCT (from the Nijmegen team - the team who claim CBT regularly leads to recovery):

Knoop H, Stulemeijer M, Prins JB, van
der Meer JWM, Bleijenberg G. Is cognitive
behaviour therapy for chronic
fatigue syndrome also effective for
pain symptoms? Behav Res Ther 2007;
45:2034-2043

Full text can be found in Knoop's PhD thesis, which is free here: http://dare.ubn.kun.nl/bitstream/2066/65596/1/65596_cognbethf.pdf

Here is the CBT section:

Cognitive Behavioral Therapy
CBT has been shown to be effective for improving
health status and fatigue in patients with CFS (65-68).
Importantly, one study found that CBT is able to improve
pain severity in adolescents and adults with CFS, even
though no specific emphasis was given to pain in the
treatment protocol (69). This is remarkable for an intervention
primarily targeting fatigue reduction and improved
functioning. Changes in physical activity, changes
in negative affectivity, or changes in body consciousness
did not explain the decrease in pain severity in response
to CBT, but the decrease in pain severity was associated
with improvements in fatigue severity (69). This suggests
that pain from CFS is directly related to chronic fatigue.
Still, these findings require replication in other settings.

On the other hand, 2 studies found that the presence
of severe pain at baseline predicts a poor response
to CBT in adult patients with CFS (69,70). This suggests
that the addition of a specific intervention targeting
pain (e.g., centrally acting drugs like serotonergic and
noradrenergic antidepressants) can potentially improve
the effects of CBT for patients with CFS who have severe
pain. Alternatively, one may optimize the CBT protocol
for patients with CFS having severe pain. This can be
done by specifically targeting maladaptive pain beliefs
like pain catastrophizing, in line with CBT protocols for
patients with chronic pain.

They later make the following claim regarding CBT (in discussion):

CBT appears to be effective for treating pain from
CFS as well.

Reviews generally don't get away with saying such things based on one paper, as far as I know.
 

Dolphin

Senior Member
Messages
17,567
Not a major point but I dislike this little section because it gives the impression there was too much specialized testing but also, I'm not sure how this leads on to
which increase thoughts and helplessness with regard
to their symptoms (“They cannot find anything, but
my pain and fatigue are real!”).

An increased understanding of pain from CFS is
important for several reasons. First, patients with CFS
struggle to understand their illness, including the nature
and meaning of “medically unexplained” symptoms
like pain and fatigue. They often have a long history
of negative findings from specialized biomedical
examinations (e.g., imaging findings, blood analyses),
which increase thoughts and helplessness with regard
to their symptoms (“They cannot find anything, but
my pain and fatigue are real!”).

---------

Musculoskeletal sources of nociception

Joint hypermobility is often characterized by impaired
motor control in end-range movements, which
might lead to recurrent micro-traumata and consequent
widespread musculoskeletal pain in hypermobile
patients. Even though the majority of patients with CFS
(58.8%) fulfill the criteria for benign joint hypermobility
ity syndrome, there is no association between musculoskeletal
pain and joint hypermobility in CFS patients
(20). Likewise, structural abnormalities in joints or muscles
of patients with CFS have not been identified repeatedly
(21,22). Thus, there is no evidence suggesting
that peripheral musculoskeletal factors account for pain
from CFS.
Later on, single studies are taken as evidence for various interventions, but single studies appear to be dismissed here if they don't suit.

-------------
The following findings are seen as evidence of generalized hypersensitivity even though there could be other explanations.


Generalized Hypersensitivity

[..]

These findings were confirmed
by Ravindran et al who used dolorimetry to examine
the average pressure causing pain at 18 tender
points, and found that patients with CFS had lower
pain thresholds than healthy controls (4). Likewise, left
lateral third intercostal space tenderness was observed
in 34 out of 42 (81%) patients with CFS and in none of
the 20 controls (35). Studies comparing the pain thresholds
patients with CFS versus those with fibromyalgia
are currently unavailable.

-------
Again, there could be other reasons e.g. study found an increase of acid following exercise:

Nevertheless, from these studies
it is concluded that none of these types of aerobic exercise
were able to activate endogenous analgesia in
patients with CFS who experience chronic widespread
pain.
 

Dolphin

Senior Member
Messages
17,567
Some more comments:

Further work is required to study the biology of the
lack of endogenous analgesia in response to exercise
for CFS. Unraveling this mechanism should lead to a
treatment of postexercise malaise (including postexercise
pain), which is a hallmark of the illness (2) and is of
particular interest in the early phases of graded exercise
therapy when patients are prone to side effects due to
exercise intolerance.
This gives impression that patients aren't prone to side effects due to exercise intolerance in phases of graded exercise
therapy which are not early phases (basically that it would disappear after a while).
-----

Pain Physiology Education

How should clinicians apply the science of chronic
pain from CFS to practice? First, it is clear that cases
where the patient is skeptical about the biopsychosocial
model, and convinced that pain and related symptoms
are due to an undetectable or “new” virus, are unlikely
to adhere to interventions like graded activity or
graded exercise therapy. Patients with “unexplained”
chronic pain who are misinformed about pain, consider
their pain as more threatening and demonstrate a lower
pain tolerance, more catastrophic thoughts, and less
adaptive coping strategies (61). Treatment adherence
for active treatments is often low in these patients.
I don't think there is evidence for either of those two statements for CFS i.e. data on adherence. The second point may follow on from ref 61 so may be ok as such, but still not proven for CFS specifically.
They seem to want patients to adhere to exercise programs even though they don't really know for sure they're safe.

Reference 61
Br J Health Psychol. 2005 Sep;10(Pt 3):441-51.
The impact of threatening information about pain on coping and pain tolerance.

Jackson T, Pope L, Nagasaka T, Fritch A, Iezzi T, Chen H.
Source

School of Psychology, James Cook University, Australia. todd.jackson@jcu.edu.au

Abstract

This study examined the impact of threatening information on coping and pain tolerance in a healthy adult sample. Prior to engaging in a Cold Pressor Test (CPT), 121 college students were randomly assigned to one of three conditions: a threat condition in which they read an orienting passage warning them about symptoms and consequences of frostbite (pain as a signal for nociception), a reassurance condition in which they read an orienting passage about the safety of the CPT (pain independent of nociception), or a control condition in which no orienting passage was read before the experimental task. Only 15.6% of participants in the threat group completed the CPT to its 4-minute duration, compared with 55.6% in the reassurance group and 45.2% of those in the control group. Even though groups did not differ on level of reported pain, threatened participants catastrophized more about the pain and reported less use of cognitive coping strategies (reinterpreting pain sensations, ignoring pain, diverting attention away from pain to other experiences, and using coping self-statements) than other respondents. A path analysis indicated that the relation between threat and pain tolerance was fully mediated by catastrophizing and cognitive coping. Together, findings suggest that pain appraised as threatening contributes to a specific pattern of coping responses associated with a reduced capacity to bear pain.

PMID: 16238858 [PubMed - indexed for MEDLINE]
 

Dolphin

Senior Member
Messages
17,567
Some more comments:

Discussion section:

Peripheral musculoskeletal factors are unlikely to account for pain from CFS.
- seems premature

------------


The observations that pain catastrophizing and
central sensitization partly account for pain from CFS
supports the notion that pain from CFS is similar to pain
from other chronic pain syndromes.

Their approach basically is that the only biology involved is central sensitization yet all they have shown is central sensitization partly accounts for pain.

------------


Still, the scientific literature on pain from CFS suggests
that pain is one out of many CFS symptoms, all
sharing a similar underlying mechanism (i.e., central
sensitization), and that pain from CFS is similar to pain
from other chronic pain syndromes. This implies that
specific treatment of pain from CFS is unnecessary, as
long as the underlying mechanism is addressed and
pain is acknowledged by the caregiver as an important
symptom.

I'm not convinced by this "logic".
 

biophile

Places I'd rather be.
Messages
8,977
LOL, I love it when sweeping generalizations are based on anecdotes or single studies of poor quality or with questionable context. It gives me such confidence in the competence of the authors and the quality of peer review.
 
Messages
13,774
Here's the study:


Surprises me also.

Ta D. I think I've read more recent research which found a much lower %. I guess that a lot will depend upon the patients being looked at, criteria used, researcher's biases/preferences, etc. (I hate CFS research).

Seeing as chronic pain is such a common problem with HMS, it seems slightly crazy for them to be so dismissive of this finding just because others with CFS suffer from pain too.
 

Hope123

Senior Member
Messages
1,266
Another activity I have no energy for but it would be good for someone to look into and write about what central sensitization is. My understanding so far is that this particular research group believes that there is no actual tissue damage from ME/CFS and that the amount of pain/ fatigue are normal bodily sensations that are amplified in our brains and that somehow, by using CBT or something like that, it will decrease the amplification and lead to recovery or substantial improvement. This is opposed to the argument put out in the ICC (and even in other fields) that pain/ fatigue are important signals that should not be ignored as they likely signify biological problems. In addition, I don't know if this groups doesn't know or simply ignores evidence like ME/CFS autopsy studies that show inflammation in the PERIPHERAL (not central) nervous system and exercise studies for instance showing abnormalities in peripheral non-neurologic systems. To me the central sensitization theory is still a lot of handwaving but I don't have the means to read through the central sensitization theory to refute it as well as I would like.

http://www.meassociation.org.uk/?p=12558
 

Tom Kindlon

Senior Member
Messages
1,734
I submitted a letter to the editor at the time but it wasn't accepted.

I've now posted it on PubMed Commons which anyone can read (although it may not be visible on some mobile devices)
Pain in patients with chronic fatigue syndrome: more research required to be confident about its etiology and treatment
http://www.ncbi.nlm.nih.gov/pubmed/22996861#cm22996861_2422

People on mobile devices may need to click "Standard PubMed" to see it (it's under the abstract).
 
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