Analgesic overuse among subjects with headache, neck, and low-back pain.

OBJECTIVES: To examine the prevalence of chronic headache (> or =15 days/month) associated with analgesic overuse in relation to age and gender and the association between analgesic overuse and chronic pain (i.e., migraine, nonmigrainous headache, neck and low-back pain). METHODS: In the Nord-Trøndelag Health Study 1995 to 1997 (HUNT-2), a total of 51,383 subjects responded to headache questions (Head-HUNT), of which 51,050 completed questions related to musculoskeletal symptoms and 49,064 questions regarding the use of analgesics. RESULTS: The prevalence of chronic headache associated with analgesic use daily or almost daily for > or =1 month was 1% (1.3% for women and 0.7% for men) and for analgesic overuse duration of > or =3 months 0.9% (1.2% for women and 0.6% for men). Chronic headache was more than seven times more likely among those with analgesic overuse (> or =1 month) than those without (odds ratio [OR] = 7.5, 95% CI: 6.6 to 8.5). Upon analysis of the different chronic pain subgroups separately, the association with analgesic overuse was strongest for chronic migraine (OR = 10.3, 95% CI: 8.1 to 13.0), intermediate for chronic nonmigrainous headache (OR = 6.2, 95% CI: 5.3 to 7.2), and weakest for chronic neck (OR = 2.6, 95% CI: 2.3 to 2.9) and chronic low-back (OR = 3.0, 95% CI: 2.7 to 3.3) pain. The association became stronger with increasing duration of analgesic use for all groups and was most evident among those with headache, especially those with migraine. CONCLUSIONS: Chronic headache associated with analgesic overuse is prevalent and especially chronic migraine is more strongly associated with frequent intake of analgesics than other common pain conditions like chronic neck and chronic low-back pain.

Analgesic use: a predictor of chronic pain and medication overuse headache: the Head-HUNT Study.

OBJECTIVE: To examine the relation between analgesic use at baseline and the subsequent risk of chronic pain (> or =15 days/month) and the risk of analgesic overuse. METHODS: In total, 32, 067 adults reported the use of analgesics in 1984 to 1986 and at follow-up 11 years later (1995 to 1997). The risk ratios (RR) of chronic pain and RR of analgesic overuse in the different diagnostic groups (i.e., migraine, nonmigrainous headache, neck pain, and low-back pain) were estimated in relation to analgesic consumption at baseline. RESULTS: Individuals who reported use of analgesics daily or weekly at baseline showed significant increased risk for having chronic pain at follow-up. The risk was most evident for chronic migraine (RR = 13.3, 95% CI: 9.3 to 19.1), intermediate for chronic nonmigrainous headaches (RR = 6.2, 95% CI: 5.0 to 7.7), and lowest for chronic neck (RR = 2.4, 95% CI: 2.0 to 2.8) or chronic low-back (RR = 2.3, 95% CI: 2.0 to 2.8) pain. Among subjects with chronic pain associated with analgesic overuse, the RR was 37.6 (95% CI: 21.3 to 66.4) for chronic migraine, 14.4 (95% CI: 10.4 to 19.9) for chronic nonmigrainous headaches, 7.1 for chronic neck pain (95% CI: 5.5 to 9.2), and 6.4 for chronic low-back pain (95% CI: 4.9 to 8.4). The RR for chronic headache (migraine and nonmigrainous headache combined) associated with analgesic overuse was 19.6 (95% CI: 14.8 to 25.9) compared with 3.1 (95% CI: 2.4 to 4.2) for those without overuse. CONCLUSION: Overuse of analgesics strongly predicts chronic pain and chronic pain associated with analgesic overuse 11 years later, especially among those with chronic migraine.

The co-occurrence of headache and musculoskeletal symptoms amongst 51 050 adults in Norway.

We have evaluated the association between headache and musculoskeletal symptoms in a large cross-sectional population-based study. Between 1995 and 1997, all 92 566 adults in Nord-Trøndelag County in Norway were invited to participate in a health survey. A total of 51 050 (55%) responded to questions concerning headache and musculoskeletal symptoms. Both migraine and non-migrainous headache were strongly associated with musculoskeletal symptoms. However, frequency of headache had a higher impact than headache diagnosis on this association. Thus, the prevalence of chronic headache (headache >14 days/month) was more than four times higher (OR = 4.6; 95% CI 4.0-5.3) in the group of individuals with musculoskeletal symptoms than in those without. Individuals with neck pain were more likely to suffer from headache as compared with those with musculoskeletal symptoms in other restricted areas. In conclusion, there was a strong association between chronic headache and musculoskeletal symptoms, which may have implications for the choice of treatment.

Vagal tone and meal-induced abdominal symptoms in healthy subjects.

BACKGROUND/AIMS: Patients with functional dyspepsia often have meal-induced dyspeptic symptoms and low vagal tone. We examined whether these variables are related in healthy subjects. METHODOLOGY: In 40 healthy subjects vagal tone and abdominal symptoms were recorded before and after a 500-ml soup meal ingested in 1 and 4 min on separate visits. Vagal tone was indexed by respiratory sinus arrhythmia (RSA). RESULTS: Scores for nausea and discomfort were higher when the soup was ingested in 1 min as compared with 4 min (nausea: p = 0.02; discomfort: p = 0.04). There was no difference in fullness or abdominal pain. RSA was unrelated to meal-induced symptom scores. RSA varied with respiration and body position: It was highest while breathing deeply in the sitting position (24.0 beats/min). With normal breathing RSA was highest in the supine position (9.0 beats/min), lower while sitting (7.0 beats/min) and lowest while standing (6.2 beats/min). CONCLUSIONS: Epigastric discomfort in response to rapid ingestion of a test meal in healthy subjects was not related to vagal tone as indexed by RSA. Vagal tone varied with breathing pattern and body position. It is possible that increasing vagal tone by such measures can be beneficial in the treatment of patients with functional dyspepsia.

Comparison of two physical exercise programs for the early intervention of pain in the neck, shoulders and lower back in female hospital staff.

The aim of the present study was to compare the effect of increased aerobic capacity versus muscle strength rehabilitation of female hospital staff with long-lasting musculoskeletal back pain. Seventy-nine women agreed to participate in the intervention study. After a medical examination, 65 individuals were assigned to one of three balanced groups: Endurance training (aerobic capacity promoting training: ET: n = 22), strength promotion exercise (SP: n = 24) or a control group (CON: n = 19). The active groups met twice a week for 60 minutes of exercise over 15 weeks. Aerobic capacity (VO2max) and musculoskeletal pain were measured immediately before (T1) and after the intervention period (T2). Aerobic capacity significantly increased in the ET group, whereas no change was observed in the SP group, and a significant reduction was found in the CON group from T1 to T2. Musculoskeletal pain was significantly reduced in both intervention groups, whereas minor changes were observed in the control group. Results from a 7-month follow-up (T3) survey confirmed the beneficial effects of interventions on musculoskeletal pain. In conclusion, improved aerobic capacity appeared not to be a necessary mechanism in musculoskeletal back pain reduction.

Fatigue and patterns of pain in fibromyalgia: correlations with anxiety, depression and co-morbidity in a female county sample.

This study explored the prevalence of fibromyalgia, the relationship of anxiety and depression with two major symptoms (pain and fatigue), and the role of co-morbidity. Participants were recruited from the Nord-Trøndelag Health Study (The HUNT Study) in Norway (N = 92,936). They were females given the diagnosis of fibromyalgia by their doctor (N = 1,816), divided into one sample without (N = 977) and another with (N = 839) co-morbidity. Owing to colinearity between anxiety and depression, extreme groups were defined according to high vs. low anxiety and depression scores. About four-fifths of the initial sample were excluded by this approach, which permitted a two x two factorial split-plot ANCOVA for the assessment of the relations of anxiety and depression with pain and fatigue. The overall prevalence was 3.2%, which obscured a highly biased sex difference with 5.2% for females and .9% for males. Results from the sample without co-morbidity (N = 977) supported the idea of independent partial correlations of anxiety and depression with pain and fatigue. A different trend was indicated in the co-morbidity sample (N = 839) where fatigue was only significantly associated with depression, whereas pain was associated with anxiety. The idea of widespread pain was supported consistently only in participants without co-morbidity who scored low on anxiety. Age, incident pain and depression contributed to a discriminant function reflecting the status of co-morbidity.

The significance of personality in pain from gallbladder stones.

BACKGROUND: The aim of the study was to investigate the association between personality factors related to coping styles and reported pain due to gallstones. METHODS: Personality trait measures were completed by 28 consecutive gallstone patients to provide estimates of positive coping resources (Life Regard Index, Sense of Coherence Scale, Sense of Humor Questionnaire) and negative coping resources (Eysenck Personality Questionnaire on Neuroticism, Tension, and Effort Stress Inventory). An overall index of gallstone-related complaints (pain) over the past 7 days/6 months was also obtained. Ultrasonography confirmed the gallstone condition. Multiple regression analyses tested the hypothesis that pain would be moderated by positive coping resources and mediated by negative coping resources. RESULTS: Reported pain was less severe with positive coping resources (39% of pain variance explained) and more severe with negative coping resources (45% of pain variance explained). CONCLUSION: The results confirm that mental coping resources have a significant role in pain differences among gallstone patients.

Quality of life, functional disability and lifestyle among subgroups of fibromyalgia patients: the significance of anxiety and depression.

This study explored the significance of anxiety and depression in quality of life, functional disability and lifestyle among fibromyalgia patients. Functional disability was defined by subjective work ability and activity-related discomfort. Lifestyle reflected habits of physical activity, regularity of meals, smoking and patterns of drinking coffee and alcohol. Members of two county divisions of fibromyalgia patients (N = 322) were investigated. Owing to colinearity between anxiety and depression scores, extreme groups were defined according to high vs. low anxiety and depression scores. Two-thirds of the initial sample were excluded by this approach which permitted a 2 x 2 factorial split-plot MANCOVA for the assessment of main effects and interaction of anxiety and depression upon quality of life, functional disability and lifestyle. Main effects of anxiety and depression were significant for index scores on activity-related discomforts, subjective work ability and quality of life, whereas depression was also significantly associated with regularity of meals. Anxiety and depression interacted to yield relatively high consumption of coffee and cigarettes among the anxious and depressed subgroup, and this effect emerged only after the elimination of confounding effects of age and duration of the fibromyalgia disease.

Depressed mood and subjective health symptoms as predictors of mortality in patients with congestive heart failure: a two-years follow-up study.

OBJECTIVE: The present study was undertaken in order to evaluate the relationship between depressed mood (depression, emotional distress) and disease-specific subjective health symptoms upon mortality risk among patients with congestive heart failure (CHF). METHODS AND RESULTS: Proportional hazard models were used to evaluate the effects of selected biomedical, subjective health and psychological variables on mortality among 119 clinically stable patients (71.4% men; mean age 65.7 years +/- 9.6) with symptomatic heart failure, recruited from an outpatient cardiology practice. Twenty deaths were registered during the twenty-four-month period of data collection, all from cardiac causes. Results indicated that depressed mood was a significant predictor of mortality with a hazard ratio of 1.9, p .002. In contrast, subjective health was not a significant predictor of mortality in a Cox regression model that included depressed mood. The hazard ratio for a 1-point increase in Zung Depression Scale score was equal to 1.08 based on the multivariate model. CONCLUSIONS: Results indicate that depressed mood is significantly related to increased mortality risk among heart failure patients. This finding is of concern to clinicians and should have implications for treatment of patients with congestive heart failure.

Functional status and depression among men and women with congestive heart failure.

OBJECTIVE: The study was designed 1) to examine the prevalence of depression in patients with congestive heart failure (CHF); 2) to explore associations between the physician's rating of functional status (NYHA class) and patient's assessment of functional status (physical limitation, dyspnea) with symptoms of depression; and 3) to explore gender related differences in relation to physician's rating and patient's rating of function status, and symptoms of depression. METHOD: A sample of 119 clinically stable heart failure patients (85 males and 34 females) was recruited from an outpatient cardiology hospital practice. The patients underwent a physical examination and completed a set of questionnaires. Prevalence of depressive symptoms and the association of these symptoms with NYHA class and patient's perceived functional status was studied. RESULTS: Findings indicate that depressive symptoms were not predominant among this sample of CHF patients. Path analyses showed non-significant direct associations between NYHA class as well as patient's perception of dyspnea with depression. In contract, the subjective indicator of physical limitations was strongly associated with symptoms of depression among the males, but this relation was not significant among the females. CONCLUSIONS: Results suggest that men and women respond differently to the burden of heart failure. However, interpretation of the results from the present study should be considered as tentative and additional research is required to examine mechanisms that explain gender differences in response to heart failure.

Social support, social disability and their role as predictors of depression among patients with congestive heart failure.

The purpose of this study was to assess the effect of social support variables, personality, clinical variables (New York Heart Associations classification), and social disability upon depression. The sample consisted of 119 clinically stable patients (34 females, 85 males) with symptomatic heart failure, recruited from an outpatient hospital practice. The patients underwent a brief physical examination and completed a set of questionnaires. Descriptive statistics were used to characterise the patients' informal functional network. The analysis revealed that the intimate social network support (spouses) and primary social network support (close family) were rated as most supportive. Results from the path analysis showed that social disability was explained by the two personality factors, neuroticism and extraversion, and by the severity of disease (NYHA). No significant effects of the social support variables upon social disability were detected. Moreover, path-analyses showed that poor intimate network support, social disability and neuroticism were significantly positively associated with depression.

The role of anxiety and depression in fatigue and patterns of pain among subgroups of fibromyalgia patients.

This study explored the relationship of anxiety and depression with two major symptoms of fibromyalgia, pain and fatigue, among fibromyalgia patients (N = 322). Due to collinearity between anxiety and depression scores, extreme groups were defined according to high versus low anxiety and depression scores. Two-thirds of the initial sample were excluded by this approach, which permitted a two by two factorial split-plot ANOVA for the assessment of main effects and the interaction of anxiety and depression upon pain and fatigue. Results stated independent, additive, effects of anxiety and depression upon levels of pain and fatigue, whereas interaction between anxiety and depression failed to significantly explain symptom differences among the participants. Correlational analyses indicated widespread pain among the low anxiety subgroups. In contrast, widespread pain was not indicated among anxious patients with low scores on depression. The findings support the hypothesis that (1) anxiety and depression are independently associated with severity of pain symptoms in fibromyalgia, and that (2) patients with high anxiety and low depression may communicate to the medical doctor in ways that involve a risk of diagnosing fibromyalgia when the criterion of widespread pain is not supported. These conclusions were confirmed by results from ANCOVAs that permitted more extensive control of collinearity among variables.

Effect of mental stress and cisapride on autonomic nerve functions in functional dyspepsia.

BACKGROUND: Disordered autonomic nerve function is frequently present in patients with functional dyspepsia (FD). In this study we investigated whether the prokinetic cisapride, which acts via acetylcholine receptors, and stress may modulate these abnormalities. METHODS: Nineteen patients (6 men, 13 women) with FD and 10 healthy subjects (3 men, 7 women) were studied after 3 days' treatment with 10 mg cisapride three times daily and placebo in a crossover design. Mental stress was induced with a videogame. Sympathetic and vagal nerve functions were assessed noninvasively by skin conductance and respiratory sinus arrhythmia, respectively. RESULTS: Vagal tone was significantly lower in FD patients than in controls both before and after mental stress (P < 0.001). Sympathetic tone was higher in patients with FD than in controls (P < 0.03). Generally, stress scores were increased by mental stress in both groups (P < 0.001). In FD patients, but not in controls, cisapride significantly increased the sympathetic tone both before (P < 0.05) and after stress (P < 0.05). CONCLUSIONS: Patients with FD have lower vagal tone and higher sympathetic tone than healthy controls. Treatment with cisapride increased sympathetic tone in the patient group but had no effect on vagal tone.

Common pathogenetic mechanisms in symptomatic, uncomplicated gallstone disease and functional dyspepsia: volume measurement of gallbladder and antrum using three-dimensional ultrasonography.

Following cholecystectomy for uncomplicated gallstone disease (GS) some patients experience persistent symptoms suggesting an underlying functional disorder. To study this phenomenon, we have compared symptomatic GS with functional dyspepsia (FD) patients and healthy individuals (C) with respect to putative pathogenetic mechanisms. Gallbladder and gastric antrum volumes were estimated with three-dimensional (3D) ultrasonography before and 10 min after ingestion of 500 ml meat soup in 18 patients with GS. Volume estimation was performed digitally after interactive manual tracing and organ reconstruction in three dimensions. Respiratory sinus arrhythmia (RSA) was calculated to index vagal tone. Abdominal symptoms were assessed by interview. The results were compared to previously published data in patients with FD and C investigated with the exact same methods. No significant differences were found between groups with respect to fasting gallbladder or gallbladder emptying. Antral volumes both fasting (P < 0.05) and postprandially (P < 0.01) were larger in GS and FD than in C. The soup meal induced dyspeptic symptoms in 2/18 (11%) of C, 12/18 (67%) of GS and 15/17 (88%) of FD patients (P < 0.001). Compared with C, both GS and FD patients had significantly decreased vagal tone (P < 0.001). There was no significant difference between GS and FD patients with respect to antral volume, vagal tone, or symptoms. We concluded that both gallstone and functional dyspepsia patients are characterized by dyspeptic symptoms in response to ingestion of 500 ml of meat soup, a wide gastric antrum, low vagal tone, but normal gallbladder size and emptying. Thus, patients with symptomatic, uncomplicated gallstone disease and functional dyspepsia seem to have common pathogenetic mechanisms.

Gastric antral motility in functional dyspepsia. Effect of mental stress and cisapride.

BACKGROUND: Disordered gastric antral motor activity may be induced by mental stress. The effect of cisapride on these abnormalities has previously not been investigated. METHODS: Ten healthy subjects and 19 patients with functional dyspepsia (FD) and erosive prepyloric changes participated in the study. Antral motility was recorded with real-time ultrasonography after ingestion of 500 ml meat soup during i) a 4-min rest period, ii) 2.5 min of mental stress, and iii) a 4-min recovery period. Patients and controls were studied after 3 days of treatment with 10 mg cisapride three times daily and placebo in a double-blind crossover design. RESULTS: Mean postprandial amplitude of antral contractions was lower in patients than controls (p < 0.001). Antral amplitude was reduced by mental stress in healthy persons (p < 0.001) but not in patients. Both fasting and postprandial antral areas were larger in FD patients than controls (p < 0.001 and p = 0.02, respectively). Cisapride reduced the fasting (p < 0.001) and the postprandial (p = 0.05) antral area in the FD group but not in controls. The soup meal produced dyspeptic symptoms in 90% of the patients and in only 10% of the controls (p < 0.001). Cisapride had no significant effect on symptoms or antral contractions. CONCLUSIONS: Mental stress induced antral hypomotility in healthy subjects but not in patients with FD who had reduced motility at base line. Cisapride reduced the enlarged fasting and postprandial antral areas in the patients but had no effect on amplitudes of antral contractions or symptoms.

Wide gastric antrum and low vagal tone in patients with diabetes mellitus type 1 compared to patients with functional dyspepsia and healthy individuals.

Autonomous neuropathy in patients with diabetes is associated with dysmotility and abdominal discomfort. The disturbances resemble to some extent those seen in patients with functional dyspepsia. To gain further insight into the disorders, we compared patients with long-standing diabetes, patients with functional dyspepsia, and healthy individuals with respect to abdominal symptoms, width of gastric antral area, and autonomic nerve function. We investigated 42 type I diabetic outpatients by structured interview for abdominal discomfort, ultrasonography of the gastric antrum, assessment of vagal and sympathetic nerve function by respiratory sinus arrhythmia and skin conductance, and measurement of blood sugar and HbA1c. Immediately after a standard meal of soup with meat, 21 (50%) of the 42 patients with diabetes complained of abdominal discomfort (pain, bloating, fullness), which was significantly less frequent (95% CI of difference 0.03-0.5) than previously seen in patients with functional dyspepsia (76%), and significantly more frequent (95% CI of difference 0.3-0.6) than that seen in healthy individuals (4%). Bloating was the most marked postprandial complaint. Mean fasting antral area was significantly wider in patients with diabetes (mean 4.9 cm2, SD 1.7) compared to healthy individuals (mean 3.5 cm2, SD 1.2), 95% CI of difference 0.6-2.2 cm2. Mean postprandial antral area was 14.8 cm2 (SD 4.6) in the patients with diabetes, which is insignificantly wider than in patients with functional dyspepsia (mean 13.0 cm2, SD 4.0) but significantly wider (95% CI of difference 1.9-6.5 cm2) than that seen in healthy individuals (mean 10.6 cm2, SD 3.8). The mean respiratory sinus arrhythmia was 0.7 beats/min (SD 0.7) in the patients with diabetes, which was insignificantly lower than that seen in patients with functional dyspepsia (2.1 beats/min, SD 4.5), and significantly lower (99% CI of difference 3.8-7.1 beats/min) compared to healthy individuals (6.2 beats/min, SD 3.8). It is concluded that patients with diabetes have a wider gastric antrum and more discomfort after a meal than healthy individuals. Compared to patients with functional dyspepsia, patients with diabetes have a wider postprandial antrum but fewer symptoms. The very low vagal tone seen in patients with diabetes may play an important role in the pathogenesis of their gastric motility disturbance and postprandial abdominal discomfort.

Psychotherapy in functional dyspepsia.

Patients with functional dyspepsia were assigned at random to cognitive psychotherapy (10 sessions of 50 min duration, n = 50) or to a control group (no treatment, n = 50). Before treatment all patients were assessed on psychological, somatic and lifestyle factors. If allocated to the therapy group all patients were also asked to define the main problems they wanted to discuss in therapy ('target complaints'). The patients were evaluated at the end of therapy (after 4 months) and at 1 yr follow-up. Outcome measures were dyspeptic symptoms, scores on 'target complaints' and psychological parameters. Both groups showed improvement in dyspeptic and psychological parameters after 1 yr. The improvement in the control group was attributed to a non- specific effect of increased interest and attention. The therapy group showed greater reduction than the control group on dyspeptic symptoms [days of epigastric pain (p = 0.050), nausea (p = 0.024), heartburn (p = 0.021), diarrhoea (p = 0.002) and constipation (p = 0.047)]; and on scores on 'target complaints' (p = 0.001).

Low vagal activity as mediating mechanism for the relationship between personality factors and gastric symptoms in functional dyspepsia.

Low vagal tone may represent a mediating mechanism for relationships between personality and symptoms of functional dyspepsia (FD) through a mechanism of antral hypomotility. Twenty-one patients with FD and seventeen healthy controls completed a series of personality tests before vagal and sympathetic activity, antral motility, and abdominal symptoms were assessed in response to a laboratory task. Functional dyspepsia patients had lower scores on vagal tone (p = .054) and motility index (p = .011) in addition to the expected higher scores on epigastric discomfort (p = .002). Psychological factors explained a substantial amount of the variance in vagal activity, antral motility, and reported symptoms. Symptoms were predicted by trait anxiety (STAI-TR), depression (BDI), and neuroticism (EPQ-N). Poor vagal tone was related to neuroticism (EPQ-N). Poor motility was best explained by task-related state dysphoria (SACL-STR).

Psychological factors and somatic symptoms in functional dyspepsia. A comparison with duodenal ulcer and healthy controls.

One hundred patients with functional dyspepsia, 100 patients with duodenal ulcer and 100 healthy controls were assessed on anamnestic factors, somatic symptoms and psychological measures. Patients with functional dyspepsia had significantly higher levels of state-trait anxiety, general psychopathology, depression, a lower general level of functioning and more somatic complaints from different organ systems, especially the musculo-skeletal system, compared to patients with duodenal ulcer and healthy controls. Patients with functional dyspepsia had more frequent dyspepsia symptoms and a longer disease history than duodenal ulcer patients. Discriminant analyses using a model of fifteen psychological and anamnestic variables, classified correctly 71.5% of the subjects due to diagnoses. The test for multiple somatic complaints (Giessener Beschwerdebogen) was the most important discriminating factor (Eigenvalue 0.78). Seventy-five per cent of the patients were correctly classified, 71% by diagnosis with respect to diagnoses of duodenal ulcer and functional dyspepsia using frequency of dyspeptic symptoms as discriminating factor (Eigenvalue 0.40). Functional dyspepsia seems to be a disease entity of its own, distinct from duodenal ulcer and strongly associated with psychological factors.