Feasibility of a dyadic intervention for management of osteoarthritis: a pilot study with older patients and their spousal caregivers.

This study evaluated a novel intervention for older osteoarthritis (OA) patients and their spousal caregivers that consisted of standard patient education supplemented by information related to effectively managing arthritis as a couple. Twenty-four female OA patients and their husbands were randomly assigned to either an educational intervention that was targeted at both patient and spouse or to a patient education intervention that was targeted at only the patient. Findings revealed that both interventions were evaluated favorably but the couple intervention was better attended than the patient intervention. In addition, patients in the couple intervention experienced greater increased efficacy in managing arthritis pain and other symptoms. The findings of this pilot study point to the utility of a dyadic intervention approach to management of OA in late life.

Cerebral responses to noxious thermal stimulation in chronic low back pain patients and normal controls.

Changes in regional cerebral blood flow (rCBF) have previously been demonstrated in a number of cortical and subcortical regions, including the cerebellum, midbrain, thalamus, lentiform nucleus, and the insula, prefrontal, anterior cingulate, and parietal cortices, in response to experimental noxious stimuli. Increased anterior cingulate responses in patients with chronic regional pain and depression to noxious stimulation distant from the site of clinical pain have been observed. We suggested that this may represent a generalized hyperattentional response to noxious stimuli and may apply to other types of chronic regional pain. Here these techniques are extended to a group of patients with nonspecific chronic low back pain. Thirty-two subjects, 16 chronic low back pain patients and 16 controls, were studied using positron emission tomography. Thermal stimuli, corresponding to the experience of hot, mild, and moderate pain, were delivered to the back of the subject's right hand using a thermal probe. Each subject had 12 measurements of rCBF, 4 for each stimulus. Correlation of rCBF with subjective pain experience revealed similar responses across groups in the cerebellum, midbrain (including the PAG), thalamus, insula, lentiform nucleus, and midcingulate (area 24') cortex. These regions represented the majority of activations for this study and those recorded by other imaging studies of pain. Although some small differences were observed between the groups these were not considered sufficient to suggest abnormal nociceptive processing in patients with nonspecific low back pain.

Task independence, safety, and adequacy among nondisabled and osteoarthritis-disabled older women.

OBJECTIVE: To examine the constructs of task independence, safety, and adequacy. METHOD: Fifty-seven nondisabled (ND) and 56 osteoarthritis-disabled (OAK) women were observed performing daily tasks. RESULTS: Intercorrelations among the constructs of independence and adequacy were uniformly high, while the relationship of safety to these constructs was moderate and more variable, although stronger in the OAK group. Task performance of the OAK group was consistently less adequate and independent than that of the ND group; however, the groups were generally equivalent in safety. For individual tasks, adequacy best differentiated between the groups. In both groups, those who performed independently also performed safely, but fewer independent OAK participants also performed totally adequately. CONCLUSION: The majority of older women who perform tasks independently also perform them safely and adequately; for a clinically significant minority, independence is not always synonymous with safe and adequate performance. Patients may be placed at risk if independence is the only construct used to determine disability.

Visceral algesia in irritable bowel syndrome, fibromyalgia, and sphincter of oddi dysfunction, type III.

Visceral hyperalgesia has been demonstrated in patients with irritable bowel syndrome who are seen in tertiary care centers. It has been hypothesized that visceral hyperalgesia may be related to psychological distress associated with health care seeking behavior in these patients. Patients with fibromyalgia and sphincter of Oddi dysfunction, type III, share many demographic and psychosocial characteristics with patients with irritable bowel syndrome and provide an opportunity to test the hypothesis that rectal hyperalgesia is unique to IBS. Fifteen patients with IBS, 10 patients with fibromyalgia, 10 with sphincter of Oddi dysfunction, type III, and 12 controls underwent evaluation of rectal pain perception in response to phasic distensions and psychological testing with a self-report instrument. Patients with irritable bowel syndrome demonstrated significantly lower rectal pain thresholds and increased levels of psychologic distress compared to controls. Although sphincter of Oddi dysfunction patients also exhibited increased psychologic distress, rectal pain perception was similar to controls. Patients with fibromyalgia exhibited rectal algesia that was not significantly different from either controls or IBS. In conclusion, rectal hyperalgesia is not a function of chronic functional pain, health care seeking behavior, or psychological distress. However, it may not be specific for IBS.

Differential responses by psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment.

OBJECTIVES: To evaluate differential treatment responses among 3 empirically derived, psychosocial subgroups of patients with fibromyalgia syndrome to a standard interdisciplinary treatment program. METHOD: Patients were classified into 1 of 3 psychosocial groups on the basis of their responses to the Multidimensional Pain Inventory. Forty-eight patients completed a 6 one-half-day outpatient treatment program consisting of medical, physical, occupational, and psychological therapies spaced over a period of 4 weeks (3 sessions the first week followed by 1 session per week for the next 3 consecutive weeks). RESULTS: Statistically significant reductions were observed in pain, affective distress, perceived disability, and perceived inteference of pain in the patients characterized by poor coping and high level of pain ("dysfunctional" group). In contrast, individuals who were characterized by interpersonal difficulties ("interpersonally distressed" group) exhibited poor responses to the treatment. "Adaptive copers," the third group, revealed significant improvements in pain but due to low pretreatment levels of affective distress and disability showed little improvement on these outcomes. CONCLUSIONS: The results provided support for the hypothesis that customizing treatment based on patients' psychosocial needs will lead to enhanced treatment efficacy. They also emphasize the importance of using appropriate outcome criteria, as low levels of problems at baseline are not likely to show significant changes following any treatment.

Interdisciplinary treatment for fibromyalgia syndrome: clinical and statistical significance.

OBJECTIVES: The primary purposes of the study were to: evaluate the treatment efficacy of an outpatient, interdisciplinary treatment program for fibromyalgia syndrome (FMS); examine whether treatment gains would be sustained for 6 months following the treatment; assess whether improvements were clinically significant; and delineate the factors associated with clinically significant improvement in pain severity. METHODS: Sixty-seven FMS patients completed a 4-week outpatient program consisting of medical, physical, psychologic, and occupational therapies. Six-month followup data were available for 66% of treated patients. RESULTS: Comparisons between pretreatment and posttreatment measures revealed significant improvements in pain severity, life interference, sense of control, affective distress, depression, perceived physical impairment, fatigue, and anxiety; however, there was no improvement in interpersonal relationships or general activities. Clinically significant improvement in pain severity, using the Reliable Change Index, was obtained by 42% of the sample and was predicted by the pretreatment levels of depression, activity, perceived disability, solicitous responses of significant others, and idiopathic onset. Pretreatment level of pain severity was not a significant predictor of the degree of pain improvement. Comparisons among pretreatment, posttreatment, and 6-month followup data revealed that the patients maintained treatment gains in pain, life interference, sense of control, affective distress, and depression. However, the quadratic polynomial analysis revealed that relapse occurred in the subjective rating of fatigue. CONCLUSIONS: The results suggest that, overall, an outpatient interdisciplinary treatment program was effective in reducing many FMS symptoms. Treatment gains tended to be maintained for at least 6 months. However, there were large individual differences in response to treatment. These results suggest that identification of subgroups of FMS patients and their specific clinical characteristics may be useful for maximizing treatment efficacy.

A standardized manual tender point survey. I. Development and determination of a threshold point for the identification of positive tender points in fibromyalgia syndrome.

OBJECTIVE: To (a) develop a standardized tender point examination protocol [Manual Tender Point Survey (MTPS)] as a diagnostic procedure to evaluate the tender point (TP) criterion for fibromyalgia syndrome (FM) and (b) determine a threshold point for positive TP. METHODS: A standardized MTPS consisted of standardized components including (a) location of the survey sites, (b) patient and examiner positioning, (c) order of examination, (d) pressure application technique, and (e) pain severity rating scores [0 (no pain) - 10 (worst pain)]. Seventy patients with FM and 70 with chronic headache were examined using the MTPS protocol. RESULTS: A pain severity score of 2 (i.e., 0-1 = negative) was found to be an optimal threshold point for identifying positive TP, with sensitivity of 88.57% and specificity of 71.43%. These results are comparable to the sensitivity and specificity of the 1990 multicenter study. CONCLUSION: The MTPS provides a step-by-step, standardized TP examination protocol, which is sensitive and specific in discriminating patients with FM from patients with chronic headache.

Effects of type of symptom onset on psychological distress and disability in fibromyalgia syndrome patients.

The purpose of the study was to investigate the differences between two types of onset (post-traumatic versus idiopathic) in pain, disability, and psychological distress in patients with fibromyalgia syndrome (FS). Forty-six FS patients with post-traumatic onset and 46 FM patients with idiopathic onset, who were matched in age and pain duration, were included in the study. All participants completed self-report inventories assessing their adaptation to the pain conditions, and during the medical examination, an examining physician completed an inventory (Medical Examination and Diagnostic Information Coding System; MEDICS) to indicate the degree of physical abnormality. The analysis revealed that the degrees of physical abnormality of the patients were comparable in the two groups. However, controlling for the involvement with financial compensation issues (e.g. disability, litigation), the post-traumatic FS patients reported significantly higher degrees of pain, disability, life interference, and affective distress as well as lower level of activity than did the idiopathic FS patients. Furthermore, evaluation of the treatment history in these patients revealed that a significantly larger number of the posttraumatic FS patients were receiving opioid medications and had been treated with nerve block, physical therapy, and TENS. The results suggest that (1) post-traumatic onset is associated with high level of difficulties in adaptation to chronic FS symptoms and (2) FS patients are a heterogeneous group of patients.

Pain, disability, and physical functioning in subgroups of patients with fibromyalgia.

OBJECTIVE: To investigate (1) whether patients with fibromyalgia (FM) could be subgrouped on the basis of psychosocial and behavioral responses to pain, and (2) the relationships among pain severity, perceived disability, and observed physical functioning, as measured by cervical spinal mobility. METHODS: 117 patients with FM received a comprehensive examination, underwent physical performance tasks during the evaluation, and completed self-report inventories. RESULTS: About 87% of the patients could be classified into the Multidimensional Pain Inventory clustering groups identified and validated in patients with a range of chronic pain problems (Dysfunctional, Interpersonally Distressed, and Adaptive Copers). Although the 3 groups exhibited comparable levels of physical functioning, the Dysfunctional and Interpersonally Distressed patients reported higher levels of pain, disability, and depression. Interpersonally Distressed patients also reported significantly lower levels of marital satisfaction than the other 2 subgroups. There were significant associations between pain severity and perceived disability, and pain severity and physical functioning, defined by spinal mobility tests. The relationship between disability and physical functioning did not reach statistical significance. Correlational analyses by subgroups revealed a significant association between patient perceived disability and physical functioning in the Adaptive Copers, but not the Dysfunctional or Interpersonally Distressed patients. CONCLUSIONS: Patients with FM can be classified into 3 subgroups based on psychosocial and behavioral characteristics. These subgroups show substantial differences in clinical presentation of their symptoms. Although the results should be considered preliminary due to the narrow range of physical functioning, the differential relationships between perceived disability and physical functioning across cluster groups suggest the importance of FM syndrome as a heterogeneous disorder. Treating patients with FM as a homogeneous group may compromise research results, impede understanding of the mechanisms underlying this condition, and deter development of effective treatment.

Diagnosis and treatment of rheumatoid arthritis.

Rheumatoid arthritis is a chronic, inflammatory, connective-tissue disease that has well-defined clinical and laboratory characteristics. The management of rheumatoid arthritis requires an aggressive multidisciplinary treatment combining both pharmacologic and nonpharmacologic measures. Using this approach, most patients with rheumatoid arthritis can maintain their functional capacity while having their pain and suffering relieved.

Lymphocyte subsets associated with T cell receptor beta-chain gene rearrangement in patients with rheumatoid arthritis and neutropenia.

OBJECTIVE: To determine the incidence of a clonal lymphoid disease in patients with chronic rheumatoid arthritis (RA) and neutropenia. METHODS: Lymphocytes from 23 RA patients with either current neutropenia or a history of this complication were studied. RESULTS: Eight patients had a clonal rearrangement of the T cell receptor beta-chain gene. Phenotypically, they showed a distinctive pattern characterized by an inverted CD4+:CD8+ cell ratio and an increased number and percentage of CD57+/CD8+ and CD3+/DR+ lymphocytes. None had evidence of a lymphoid malignancy. CONCLUSION: Among RA patients with neutropenia, there is a subset who have a subclinical disease resembling T gamma lymphoproliferative disease.

Recurrence of adult Still's disease after pregnancy.

A 35-year-old white woman had recurrent episodes of adult onset Still's disease after 2 successive pregnancies. The second episode was characterized by an erythematous, macular rash, arthritis, fevers and hepatic dysfunction which occurred 2 months postpartum. The recurrent illness after pregnancy suggests that adult onset Still's disease may be influenced by gestational status.

Efficacy of combined therapy with plasmapheresis and immunosuppressants in rheumatoid vasculitis.

The combined effects of plasmapheresis and immunosuppressive therapy in the treatment of rheumatoid vasculitis was evaluated in 8 patients. These modalities, in combination, proved to promote rapid healing of cutaneous ulcers. In addition, it appeared that this aggressive therapy can occasionally reverse early gangrenous lesions involving extremities. By contrast, little change occurred in longstanding neuropathic manifestations. Our preliminary results suggest that plasmapheresis, used as an acute treatment modality, and combined with prolonged therapy with immunosuppressive drugs, may reduce the morbidity associated with certain manifestations of rheumatoid vasculitis.

Changes in coagulation factors, complement, immunoglobulins, and immune complex concentrations with plasma exchange.

Seventeen patients with a spectrum of immunologically-related disorders were studied before and immediately after plasma exchange (PE) for changes in coagulation factors, complement, immunoglobulins, and immune complex levels. Each PE replaced 50 per cent of the plasma volume with 5% albumin and saline. With PE, coagulation profiles indicated a decrease of 23 to 55 per cent in the levels of fibrinogen, Factors II, V, VII, VIII, IX, X, XI, XII, and Fletcher factor. Only minimal changes were noted in the prothrombin time and activated partial thromboplastin time. Most coagulation factors, except fibrinogen, returned to baseline by 48 hours. Following three PE/week, fibrinogen was reduced by 51 per cent; other factors were not significantly altered. C3 and C4 fell by 35 to 40 per cent with each PE; these approached baseline by 24 hours. Immunoglobulins (G,A,M) were reduced by 34 +/- 3,37 +/- 3 and 34 +/- 3 per cent, respectively. After three PE, the total immunoglobulins were decreased by 50 to 55 per cent. Five of eight patients who had three or more PE developed hypogammaglobulinemia (IgG less than 450 mg/dl). Immune complexes were reduced by 50 +/- 4 per cent with each PE. Multiple exchanges in five patients led to a greater reduction (80 +/- 6%). Thus PE was an effective means of reducing immune complexes but led to hypogammaglobulinemia and hypofibrinogenemia.