Angela K. Lyden

Cerebrospinal Fluid Corticotropin-Releasing Factor Concentration is Associated with Pain but not Fatigue Symptoms in Patients with Fibromyalgia

Previous studies have identified stress system dysregulation in fibromyalgia (FM) patients; such dysregulation may be involved in the generation and/or maintenance of pain and other symptoms. Corticotropin-releasing factor (CRF) is the principal known central nervous system mediator of the stress response; however, to date no studies have examined cerebrospinal fluid (CSF) CRF levels in patients with FM. The relationship between CSF CRF level, heart rate variability (HRV), and pain, fatigue, and depressive symptoms was examined in patients with FM. Among participants (n=26), CSF CRF levels were associated with sensory pain symptoms (r=0.574, p=0.003) and affective pain symptoms (r=0.497, p=0.011), but not fatigue symptoms. Increased HRV was also strongly associated with increased CSF CRF and FM pain. In multivariate analyses adjusting for age, sex, and depressive symptoms, the association between CSF CRF and sensory pain symptoms (t=2.54, p=0.027) persisted. Women with FM who reported a history of physical or sexual abuse had lower CSF CRF levels than women who did not report such a history. CSF CRF levels are associated with both pain symptoms and variation in autonomic function in FM. Differences in CSF CRF levels among women with and without a self-reported history of physical or sexual abuse suggest that subgroups of FM patients may exist with different neurobiological characteristics. Further studies are needed to better understand the nature of the association between CSF CRF and pain symptoms in FM.

Subgroups of older adults with osteoarthritis based upon differing comorbid symptom presentations and potential underlying pain mechanisms

IntroductionAlthough people with knee and hip osteoarthritis (OA) seek treatment because of pain, many of these individuals have commonly co-occurring symptoms (for example, fatigue, sleep problems, mood disorders). The purpose of this study was to characterize adults with OA by identifying subgroups with the above comorbid symptoms along with illness burden (a composite measure of somatic symptoms) to begin to examine whether subsets may have differing underlying pain mechanisms.MethodsCommunity-living older adults with symptomatic knee and hip OA (n = 129) participated (68% with knee OA, 38% with hip OA). Hierarchical agglomerative cluster analysis was used. To determine the relative contribution of each variable in a cluster, multivariate analysis of variance was used.ResultsWe found three clusters. Cluster 1 (n = 45) had high levels of pain, fatigue, sleep problems, and mood disturbances. Cluster 2 (n = 38) had intermediate degrees of depression and fatigue, but low pain and good sleep. Cluster 3 (n = 42) had the lowest levels of pain, fatigue, and depression, but worse sleep quality than Cluster 2.ConclusionsIn adults with symptomatic OA, three distinct subgroups were identified. Although replication is needed, many individuals with OA had symptoms other than joint pain and some (such as those in Cluster 1) may have relatively stronger central nervous system (CNS) contributions to their symptoms. For such individuals, therapies may need to include centrally-acting components in addition to traditional peripheral approaches.

Effects of activity strategy training on pain and physical activity in older adults with knee or hip osteoarthritis: A pilot study

OBJECTIVE To examine effects of activity strategy training (AST), a structured rehabilitation program taught by occupational therapists and designed to teach adaptive strategies for symptom control and engagement in physical activity (PA). METHODS A randomized controlled pilot trial was conducted at 4 sites (3 senior housing facilities and 1 senior center) in southeastern, lower Michigan. Fifty-four older adults with hip or knee osteoarthritis (mean +/- SD age 75.3+/-7.1 years) participated. At each site, older adults were randomly assigned to 1 of 2 programs: exercise plus AST (Ex + AST) or exercise plus health education (Ex + Ed). The programs involved 8 sessions over 4 weeks with 2 followup sessions over a 6-month period, and were conducted concurrently within each site. Pain, total PA and PA intensity (measured objectively by actigraphy and subjectively by the Community Healthy Activities Model Program for Seniors questionnaire), arthritis self-efficacy, and physical function were assessed at baseline and posttest. RESULTS At posttest, participants who received Ex + AST had significantly higher levels of objective peak PA (P=0.02) compared with participants who received Ex + Ed. Although not statistically significant, participants in Ex + AST tended to have larger pain decreases, increased total objective and subjective PA, and increased physical function. No effects were found for arthritis self-efficacy. CONCLUSION Although participants were involved in identical exercise programs, participants who received AST tended to have larger increases in PA at posttest compared with participants who received health education. Future studies will be needed to examine larger samples and long-term effects of AST.

Association between pain, radiographic severity, and centrally-mediated symptoms in women with knee osteoarthritis.

To examine the relationship between pain, radiographic severity, and a common set of co‐occurring centrally‐mediated symptoms (fatigue, sleep quality, and depression) in women with knee osteoarthritis.

Static Versus Dynamic Splinting for Proximal Interphalangeal Joint Pyrocarbon Implant Arthroplasty: A Comparison of Current and Historical Cohorts

STUDY DESIGN Nonrandomized mixed current and historical cohort follow-up study. The purpose of the study was to test the effectiveness of static splinting after arthroplasty in patients with osteoarthritis. Dynamic splinting is recommended after proximal interphalangeal joint pyrocarbon implant arthroplasty; however, static splinting may be more feasible to deliver. Nine consecutive patients received static splinting in this study. These patients were compared with those of a historical control group (n = 10) who received dynamic splinting. Function and performance variables were measured preoperatively and 3 months after surgery. All patients underwent surgery by the same hand surgeon, and most of the patients were treated by the same certified hand therapist. Both static and dynamic groups showed improvement on several function and performance measures. Compared with the dynamic group, the static group showed greater improvements in the Michigan. Hand Outcomes Questionnaire subset of work performance (21.00 ± 14.75 vs 3.13 ± 14.13, p < 0.05) and Jebsen-Taylor Test (-11.58 ± 5.44 vs -2.81 ± 3.23, p < 0.03). Patients who received static splinting had similar outcomes to those who received the dynamic splinting. Static splinting requires less therapist training and offers greater patient convenience and is a promising protocol that should be evaluated in a larger study.

Characterizing Pain Flares From the Perspective of Individuals With Symptomatic Knee Osteoarthritis.

Although pain in knee osteoarthritis (OA) commonly affects activity engagement, the daily pain experience has not been fully characterized. Specifically, the nature and impact of pain flares is not well understood. This study characterized pain flares as defined by participants with knee OA. Pain flare occurrence and experience were measured over 7 days.

Pain, Fatigue, and Physical Activity in Osteoarthritis: The Moderating Effects of Pain- and Fatigue-Related Activity Interference

OBJECTIVE To examine how self-reported pain- and fatigue-related activity interference relates to symptoms and physical activity (PA) in daily life among people with knee or hip osteoarthritis. DESIGN Cross-sectional study with a 7-day repeated-measures assessment period. SETTING General community. PARTICIPANTS Participants (N=154; mean age, 65y; 60% women [n=92]) with knee or hip osteoarthritis and pain lasting ≥3 months. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Pain- or fatigue-related activity interference items on the Brief Pain Inventory or Brief Fatigue Inventory, respectively, from baseline survey, momentary pain and fatigue severity (measured 5times/d for 7d), and PA measured with a wrist-worn accelerometer over 7 days. We hypothesized that perception of pain- and fatigue-related activity interference would moderate the association between symptoms (pain or fatigue) and PA. People with higher pain- or fatigue-related activity interference were thought to have stronger negative associations between momentary ratings of pain and fatigue and PA than did those with lower activity interference. RESULTS Pain-related activity interference moderated the association between momentary pain and PA, but only in the first part of the day. Contrary to expectation, during early to midday (from wake-up time through 3 pm), low pain-related interference was associated with stronger positive associations between pain and PA but high pain-related interference was associated with a small negative association between pain and PA. Fatigue-related activity interference did not moderate the relation between fatigue and activity over the course of a day. CONCLUSIONS Depending on a persons reported level of pain-related activity interference, associations between pain and PA were different earlier in the day. Only those with high pain-related activity interference had lower levels of PA as pain increased and only in the morning. High pain-related activity interference may be important to address, particularly to maintain PA early in the day despite pain.

Brief Time-Based Activity Pacing Instruction as a Singular Behavioral Intervention was not Effective in Participants with Symptomatic Osteoarthritis.

Abstract Osteoarthritis (OA) of the lower extremities is a prevalent cause of disability in which symptoms interfere with mobility and activity participation. Behavioral self-management for OA symptomatology is commonly recommended; but these interventions are underutilized, unstandardized in application, and at times, unavailable in the context of clinical care. For people with chronic pain, rehabilitation professionals may select to apply activity pacing instruction as one behavioral strategy to manage symptoms. Activity pacing is widely used in combination with other pharmacological and behavioral interventions but has not been studied as a singular behavioral intervention for people with OA. The purpose of this study was to evaluate the effectiveness of an occupational therapist-delivered, time-based activity pacing program for treatment of pain, fatigue, and physical function in people with symptomatic knee or hip OA. A 3-arm randomized controlled trial was conducted in which 193 people were randomized into tailored activity pacing, general activity pacing, or usual care arms. Assessments were done at 10 weeks and 6 months after baseline. Using linear mixed models, Western Ontario and McMaster Universities Osteoarthritis Index pain scores changed over time, decreasing the most in the general and usual care groups; only the usual care group had decreased pain over 6 months. The tailored and general activity pacing groups reported higher frequency of pacing behaviors than the usual care group at 10 weeks, but pacing was not sustained at 6 months. This trial does not support the use of time-based pacing as a singular behavioral strategy for people with knee or hip OA.

The Physical Activity Daily (PAD) Trial: The rationale and design of a randomized controlled trial evaluating an internet walking program to improve maximal walking distance among patients with peripheral arterial disease

BACKGROUND Despite established guidelines for regular walking as a first line therapy for adults with peripheral arterial disease (PAD), most patients do not walk routinely. This paper presents the design specifications for a randomized clinical trial to examine the effectiveness of an internet-based walking program compared to a telephone intervention, or the combination (internet-based with telephone counseling) for promotion of regular walking in patients with PAD. METHODS Sedentary adults with documented lower extremity PAD are being recruited from the University of Michigan Health System and the surrounding area. Participants are randomized to one of four arms in a 2×2 factorial design: 1) telephone counseling to promote walking, 2) an internet-based walking program with tailored step-count goals, 3) the combination of telephone counseling with the internet-based walking program, or 4) waitlist control. Participants receive a 4-month intervention phase, after which all participants are followed for an additional 8months to assess long-term adherence to regular walking. Outcomes are assessed at baseline, 4 and 12months. The primary outcome is walking distance assessed through a standardized treadmill protocol. Additional outcomes include change in step-counts measured with a commercial activity tracker, pain-free walking distance, and changes in health-related quality of life from baseline to follow-up. CONCLUSION Finding effective and feasible programs to promote walking among PAD patients is warranted. This study will add to current evidence regarding use of internet based programs with and without telephone counseling to promote regular walking in this population.

Effect of Aromatase Inhibitor Therapy on Sleep and Activity Patterns in Early-stage Breast Cancer

Introduction: Adherence to aromatase inhibitor (AI) therapy is poor, often because of treatment‐emergent side effects, including musculoskeletal symptoms, fatigue, and insomnia. In the present analysis, we examined the sleep patterns and daytime function both objectively using actigraphy and subjectively using validated questionnaires in women initiating AI therapy. Patients and Methods: Postmenopausal women with stage 0‐III hormone receptor‐positive breast cancer who were initiating AI therapy were eligible. The patients wore actigraphy devices for 10 consecutive days and completed questionnaires at baseline before the initiation of AI and after 3 months of AI therapy. Associations between the baseline demographics and symptoms, changes in patient‐reported outcomes and actigraphy measures from baseline to 3 months of AI therapy and discontinuation of AI therapy were examined using sign tests, logistic regression models, Spearmans correlation, and linear mixed models. Results: Forty‐two patients (86%) completed the baseline assessments and 23 patients (47%) completed both the baseline and the 3‐month assessments. Objectively measured daytime function as measured by total daytime activity decreased during the 3 months after starting AI (232,566 activity count vs. 204,205 activity count; P = .023), and the decrease was more evident in women with higher baseline physical function. Reduced daytime activity correlated with increased fatigue (&rgr; = −0.49; P = .017). Conclusion: Daytime function decreased after initiation of AI therapy and correlated moderately with increased fatigue, although no association was identified with changes in pain or sleep quality. Additional studies are required to understand why function is reduced, which could have implications for interventions to improve patient tolerance of, and persistence with, AI therapy.