Françoise Laroche

Classification of and Risk Factors for Estrogen Deprivation Pain Syndromes Related to Aromatase Inhibitor Treatments in Women With Breast Cancer: A Prospective Multicenter Cohort Study

UNLABELLED Aromatase inhibitors (AIs) are the first-line treatment in women with breast cancer for total estrogen depletion. Half the treated women may develop pain, and this condition may therefore be seen as a clinical model of pain related to estrogen deprivation. In this prospective multicenter study, we classified AI-related pain syndromes and identified their predictors. A 1-year, prospective, multicenter cohort study, with 6 visits, was carried out on 135 women with early-stage breast cancer and no pain at the start of AI treatment. At initial assessment, we investigated clinical (demographic and psychosocial, cancer characteristics and treatment, sleep, quality of life), biological (sex hormones, vitamin D, bone biomarkers, oxidative stress, immunologic and inflammatory markers), environmental, and genetic (polymorphism for pain mechanisms) risk factors for pain. During 1 year of follow-up, 77 women (57%) developed pain, leading to AI discontinuation in 12 cases. Five pain syndromes were identified: joint pain (36%), diffuse pain (22%), tendinitis (22%), neuropathic pain (9%), and mixed pain (11%), which are mostly persistent (57%), with diffuse and joint pains the most intense. Risk factors for the development of pain included higher levels of anxiety and impaired quality of life at the initial assessment, whereas cancer characteristics, genetic background, inflammation, and immunologic and hormonal status at baseline were not significant predictors. PERSPECTIVE This article presents a classification of AI-related pain syndromes induced by estrogen deprivation that were previously described as arthralgia, but not as neuropathic, diffuse, and mixed pain. This estrogen deprivation-related condition represents a clinical model of pain, and our study identified mostly psychological risk factors for pain development.

“Let’s Talk about OA Pain”: A Qualitative Analysis of the Perceptions of People Suffering from OA. Towards the Development of a Specific Pain OA-Related Questionnaire, the Osteoarthritis Symptom Inventory Scale (OASIS)

Introduction Pain is the primary outcome measurement in osteoarthritis, and its assessment is mostly based on its intensity. The management of this difficult chronic condition could be improved by using pain descriptors to improve analyses of painful sensations. This should help to define subgroups of patients based on pain phenotype, for more adapted treatment. This study draws upon patients’ descriptions of their pain, to identify and understand their perception of osteoarthritis pain and to categorize pain dimensions. Methods This qualitative study was conducted with representative types of patients suffering from osteoarthritis. Two focus groups were conducted with a sample of 14 participants, with either recent or chronic OA, at one or multiple sites. Focus groups were semi-structured and used open-ended questions addressing personal experiences to explore the experiences of patients with OA pain and the meanings they attributed to these pains. Results Two main points emerged from content analyses: -A major difficulty in getting patients to describe their osteoarthritis pain: perception that nobody wants to hear about it; necessity to preserve one’s self and social image; notion of self-imposed stoicism; and perception of osteoarthritis as a complex, changing, illogical disease associated with aging. -Osteoarthritis pains were numerous and differed in intensity, duration, depth, type of occurrence, impact and rhythm, but also in painful sensations and associated symptoms. Based on analyses of the verbatim interviews, seven dimensions of OA pain emerged: pain sensory description, OA-related symptoms, pain variability profile, pain-triggering factors, pain and physical activity, mood and image, general physical symptoms. Summary In osteoarthritis, pain analysis should not be restricted to intensity. Our qualitative study identified pain descriptors and defined seven dimensions of osteoarthritis pain. Based on these dimensions, we aim to develop a specific questionnaire on osteoarthritis pain quality for osteoarthritis pain phenotyping: the OsteoArthritis Symptom Inventory Scale (OASIS).

Pain management in heroin and cocaine users.

Drug addicts often seek medical help for pain. Numerous fears and beliefs may hinder the recognition, evaluation, and management of pain in addicts. Nevertheless, the same fundamental principles apply to these patients as to other patients in terms of pain evaluation, analgesic selection, and dosage adjustment. Clarity of the medical prescription is crucial. Specific points that require attention in addicts include the effects of the abused drugs on the nociceptive system, the nature and amount of abused drugs, concomitant nondrug addictions, co-morbidities, and the nature of the pain symptoms. Also crucial is differentiating current abusers from former abusers and from abusers taking replacement therapy, as different management strategies are required in these three situations. Detailed information on the history of drug abuse is necessary to avoid unwanted events (e.g., overdosing or withdrawal syndrome) or an exacerbation of the addictive behaviors. In practice, hospital admission should be avoided to the extent possible. The use of strong opioids should be kept to a minimum (although this important rule may be difficult to follow, for instance in surgical emergencies). The best route of administration and galenic formulation vary with each individual situation but, in general, intravenous administration of strong opioids is highly undesirable. A treatment contract established with the patient is crucial and must indicate the nature of the drug or replacement agent used and the treatments given for pain control.

Are joint and soft tissue injections painful? Results of a national French cross-sectional study of procedural pain in rheumatological practice

BackgroundJoint, spinal and soft tissue injections are commonly performed by rheumatologists in their daily practice. Contrary to other procedures, e.g. performed in pediatric care, little is known about the frequency, the intensity and the management of procedural pain observed in osteo-articular injections in daily practice.MethodsThis observational, prospective, national study was carried out among a French national representative database of primary rheumatologists to evaluate the prevalence and intensity of pain caused by intra-and peri-articular injections, synovial fluid aspirations, soft tissue injections, and spinal injections. For each physician, data were collected over 1 month, for up to 40 consecutive patients (>18-years-old) for whom a synovial fluid aspiration, an intra or peri-articular injection or a spinal injection were carried out during consultations. Statistical analysis was carried out in order to compare patients who had suffered from pain whilst undergoing the procedure to those who had not. Explanatory analyses were conducted by stepwise logistic regression with the characteristics of the patients to explain the existence of pain.ResultsData were analysed for 8446 patients (64% female, mean age 62 ± 14 years) recruited by 240 physicians. The predominant sites injected were the knee (45.5%) and spine (19.1%). Over 80% of patients experienced procedural pain which was most common in the small joints (42%) and spine (32%) Pain was severe in 5.3% of patients, moderate in 26.6%, mild in 49.8%, and absent in 18.3%. Pain was significantly more intense in patients with severe pain linked to their underlying pathology and for procedures performed in small joints.Preventative or post-procedure analgesia was rarely given, only to 5.7% and 36.3% of patients, respectively. Preventative analgesia was more frequently prescribed in patients with more severe procedural pain.ConclusionMost patients undergoing intra-or peri-articular injections, synovial fluid aspirations and spine injections suffer from procedural pain. Most patients experience usually mild procedural pain and procedural pain management is uncommonly provided by physicians. Specific research and guidelines for the management of procedural pain related to rheumatologic care should be established to improve the quality of care provided by physicians.

Relieving pain in rheumatology patients: Repetitive transcranial magnetic stimulation (rTMS), a developing approach

Transcranial magnetic stimulation (TMS) is a non-invasive method for activating specific areas of the brain. There are two variants, repetitive TMS (rTMS) and direct TMS. Rapid changes in an electrical current induce a magnetic field, which in turn induces an electrical current in a nearby conductor. When a coil is positioned over the brain, rTMS delivers very brief and painless magnetic pulses to the brain. Initially, rTMS was developed as a treatment for depression. Since then, potential indications have been extended to the treatment of chronic pain, most notably in patients with rheumatic diseases. Thus, active research is being conducted into rTMS effects in fibromyalgia, chronic low back pain, and type I complex regional pain syndrome. Studies have established that rTMS is safe; provides pain relief, at least in the short-term; and improves the psychological correlates of chronic pain. These data support further development efforts with the goal of using rTMS in patients with chronic pain, including those with rheumatic diseases. French physicians have shown a high level of interest in rTMS, and the first French recommendations for using this method were issued in 2011. Further research is needed to determine the optimal stimulation parameters, session frequency, and session duration, as well as the best indications. Physicians who see many patients with chronic pain, such as rheumatologists, should be aware of this developing non-pharmacological and safe treatment modality, which can be of considerable help to their patients.

Quality of life and impact of pain in women treated with aromatase inhibitors for breast cancer. A multicenter cohort study

Women with hormone-dependent breast cancer are treated with aromatase inhibitors (AI) to slow disease progression by decreasing estrogen levels. However, AI have adverse effects, including pain, with potentially serious impact on quality of life (QOL) and treatment compliance. We evaluated quality of life during the first year of AI treatment, focusing particularly on the impact of pain. In a multicenter cohort study of 135 women with early-stage breast cancer, free of pain at the initiation of AI treatment, quality of life (by the EORTC QLQ-BR23), somatic and psychic symptoms, psychological characters, temperament and coping strategies were assessed at baseline and at each follow-up visit (1, 3, 6 and 12 months). The impact of treatment-induced pain on quality of life during follow-up was determined with repeated-measures regression models. These models were constructed to assess the effects of pain and pain type on quality of life during follow-up, taking into account predictors associated with quality of life at baseline. Prior ganglion resection, taxane treatment and chemotherapy, a high amplification score on the pain catastrophizing scale, and a high harm avoidance score on the personality questionnaire were associated with a significantly lower baseline QOL. Fifty-seven percent of women developed pain of five different types: upper or lower limb joint pain, diffuse pain, neuropathic pain, tendon pain and mixed pain. A significant decrease in QOL was noted in the women with pain, particularly for body image, sexual functioning and future perspectives. Moreover, the impact of pain on QOL depended on the type of pain experienced. In conclusion, women treated with aromatase inhibitors display changes in quality of life and the degree of change in quality of life depends mostly on the type of pain experienced. Oncologists and patients should be aware of painful adverse effects of AI and encouraged to provide or receive earlier and more appropriate management of these effects.

OP0274 Fibromyalgia in real life: a national french web-based survey in 4516 patients

Background Fibromyalgia (FM) is the most frequent widespread chronic pain disorder (1,6% of the French population) (1). The medical and socioeconomic burden is high and severity depends on medical status and symptoms as defined by the OMERACT criteria (2). Most of the studies are performed in specialized centers, recruiting the most severe patients, but very few data exist on its real impact on daily life. Objectives The aims were to collect demographic data, symptoms, function, diagnosis, management strategies and health care utilization in real life, in a large population, and to determine clusters of patients. Methods A large internet-based national survey of people suffering from FM was developed by a national patient association (Fibromyalgie-SOS Association) on their website, in France in 2014. The survey included 103 qualitative and quantitative questions that were developed by 3 medical experts (including rheumatologists) and patients. Results The questionnaire was completed by 4516 people. Respondents were predominantly middleaged (48 yrs) females (93%), most of whom had FM symptoms duration for 12 years and a diagnosis for 5 years. Diagnosis was made by a rheumatologist in 54% of the cases. The symptoms were concordant with the OMERACT domains (chronic pain, fatigue stiffness and other FM-associated symptoms) as previously published by Bennett in 2007 (3). The mean FIQ (Fibromyalgia Impact Questionnaire) score was 51 (0–100). 55% were currently working but 65% of them have been on sick leave in the 12 previous months. FIQ was mostly impacted by injustice feeling (+4.5), part time job (+2.4) and low income - less than 1000 euros monthly (+2.3) (linear regression). Somatic comorbidities were mostly osteoarthritis (49%). Psychological comorbidities were injustice feeling (77%), cognitive symptoms (62%), anxiety (52%) and depression (48%). Initiating factors were reported by 73% of them: physical (50%) and/or psychological (76%). Aggravating factors included excess of activities, conflicts, traumatism and displacement. Treatments were provided by general practitioner (85%), physiotherapist (63%), rheumatologist (54%) and osteopathic manual practitioner (41%). Treatment was prescribed in 76.6% of the patients, including paracetamol alone (51.4%), paracetamol and weak opioids (64%), strong opioids (20.1%), antidepressants (81.5%), antiepileptic agents (54.5%), nonsteroidals NSAIDs (53.8%), anxiolytics (52.4%) and steroids (12.8%). Conclusions This unique descriptive survey in a large population provides data on symptoms, emotional distress, prescribing habits and impact of FM on daily life and work. Results show that FM is altered by emotional (including injustice feeling) and socio-economic factors. References Perrot S, Vicaut E, Servant D, Ravaud P. Prevalence of fibromyalgia in France: a multi-step study research combining national screening and clinical confirmation: The DEFI study (Determination of Epidemiology of Fibromyalgia). BMC Musculoskeletal Disorders 2011; 12:224. Mease P, Clauw D, Arnold L. and the OMERACT Fibromyalgia Working Group. The Journal of Rheumatology, 2011; 38: 1487–95. Bennett R. Jones J, Turk D, Russell I, Matallana L. An internet survey of 2,596 people with fibromyalgia. BMC Musculoskeletal Disorders 2007, 8:27: 1–11. Disclosure of Interest None declared

THU0470 Work and professional recognition in fibromyalgia patients – a national french web based survey on sick leave in 1870 fibromyalgia female patients

Background Fibromyalgia (FM) induces work limitations with an increase of number of days of sick leave 3 to 4 fold higher (1, 2). Objectives Our objectives were to analyze work status, to determine risk factors for sick leave and to compare women working to women in sick leave during the past 12 months in a female population with FM. Methods 1870 female workers suffering from FM were selected from a large internet-based national survey of 4516 responders (Fibromyalgie-SOS Association website in France in 2014). Women having a FIRST score ≥5/6 were included. Results 1870 patients participated to the survey: 955 with full time job, 149 with part time job (related to FM status) and 766 on sick leave (7% 1–3 months, 27.3% 3–12 months and 62% >12 months). Fibromyalgia Impact questionnaire (FIQ) score was slightly lower in the 1104 patients currently working compared to the 766 on sick leave (56 versus 58.7), but not clinically different. 64,5% of the population have been on sick leave during the last 12 months (average duration: 37 mean days for full time job and 122 among those with part time job). Women being in sick leave were older (p<0,0001), single (p=0,0321), had less financial income (p<0,0001), used more antidepressants (p=0,0085) and more anti epileptics (p=0,0102). Recognition of FM by occupational physicians or social security doctors were lower among the workers (p<0.0001). In the 1104 currently working, more than 33% have never been visiting their occupational physician and 44,2% rarely. They reported no support from these doctors (p=0,0011) particularly those having not being on sick leave. Independent criteria of sick leave were transportation time (p=0.0131), work difficulties (p=0.0031), hinders career progress (p=0.0196), sedentary occupation and repetitive work (p=0.0195). Conclusions These data on a large fibromyalgia population shows that clinical status and also professional factors may influence work ability and sick leave. The work factors include work difficulties, transportation time, sedentary and repetitive occupation. These results should be taken into account by the work professionals in order to facilitate work capacity in FM patients. References Sicras-Mainar A, Rejas J, Navarro R, Blanca M, Morcillo A, Larios R, Velasco S VillarroyaC. Treating patients with fibromyalgia in primary care settings under routine medical practice: a claim database cost and burden of illness study. Arthritis Research & Therapy 2009, 11:R54. White K. Comparing self-reported function and work disability in 100 community cases of fibromyalgia syndrome versus controls in London, Ontario: the London Fibromyalgia Epidemiology Study. Arthritis Rheum. 1999;42:76–83. Acknowledgements Fibromyalgia SOS french Association. Disclosure of Interest None declared

TO66 Thérapie comportementale et cognitive de la fibromyalgie : étude pilote au centre d’évaluation et de traitement de la douleur Saint-Antoine – Paris

Rationnel Le traitement de la fibromyalgie necessite une approche multidisciplinaire proposee par la Therapie Comportementale et Cognitive (TCC). Objectifs Amelioration de la qualite de vie des patients souffrant de fibromyalgie par la TCC. Materiel et methode Etude ouverte, prospective, incluant 25 patients (80 % de femmes) d’âge moyen 49,2 ans souffrant de fibromyalgie. Le programme de TCC comprend 8 sessions hebdomadaires de 2 heures chacune, animees par un medecin et un psychologue, en groupe de 5 a 8 patients. La TCC comporte un travail d’education therapeutique, de reformulation cognitive, d’apprentissage des strategies de « coping », de reprise d’activites physiques, de gestion du stress, et de la relaxation. Resultats Les questionnaires EVA douleur, QIF (Questionnaire d’Impact de la Fibromyalgie) sont remplis par les patients (debut/fin programme). N = 25 patients (test de Student). Les resultats montrent une amelioration significative du score global du QIF (diminution de 28,41 %) et des autres items du QIF : diminution de 24,59 % de la douleur moyenne ressentie au cours des 7 derniers jours, diminution de 23,55 % de la fatigue matinale et de 21,18 % de la fatigue generale, augmentation de 29,22 % du nombre de jours de bien-etre, diminution de la tendance depressive de 28,30 %, amelioration de la raideur articulaire de 24,83 % et augmentation de la capacite fonctionnelle de 15,57 %. Diminution de l’EVA de 1,13 (p Discussion-Conclusion Cette etude pilote dont les resultats preliminaires sont encourageants, a permis de tester le programme et d’harmoniser le travail des differents intervenants. Notre objectif est de debuter fin 2007, un programme de recherche regional (PHRC), monocentrique, prospectif, randomise, controle, avec suivi pendant 12 mois.

TO61 Facteurs de risque des douleurs induites par les infiltrations articulaires et rachidiennes : étude prospective multicentrique chez 1 350 patients consultant en rhumatologie

Rationnel Il n’existe pas de donnees sur les facteurs predictifs des douleurs induites par les infiltrations. Objectifs (1) identifier les facteurs predictifs des douleurs induites par les ponctions/infiltrations (P-I) du genou et infiltrations (I) du rachis (2) evaluer les differentes approches therapeutiques preventives et curatives (3) evaluer l’efficacite de la prise en charge. Patients et methode Etude prospective, multicentrique chez les rhumatologues (RH) francais et leurs patients (pts) ambulatoires. Chaque RH devait inclure 6 pts consecutifs pour lesquels une PI ou une I etait necessaire au genou ou au rachis. Les pts et les RH devaient remplir des questionnaires avant et apres, et a 48 heures. Resultats 249 RH ont ete recrutes entre octobre 2006 et janvier 2007, permettant l’inclusion de 1 350 patients (53 % pour le genou, 47 % pour le rachis ; 64,59 % de femmes). Une douleur lors du geste etait presente dans 80 % des cas (78,6 % pour le genou vs 81,6 % pour le rachis), sans difference significative d’intensite entre les 2 localisations. L’intensite de la douleur induite dependait du niveau d’anxiete prealable, du vecu d’un geste anterieur, de l’intensite de la douleur dans la semaine precedente. Pour le genou seulement, l’intensite de la douleur induite etait liee a l’etat evolutif de la pathologie sous-jacente et au type de produit utilise (l’I d’acide hyaluronique est moins douloureuse que l’I de corticoides). Pour le rachis seulement, la frequence des douleurs severes etait significativement augmentee en cas de comorbidites. Dans les deux cas, l’apparition d’une douleur induite ne dependait pas du sexe des patients, de l’âge, de l’activite physique ou professionnelle. Il n’existait pas de concordance entre le medecin et son patient dans l’evaluation de la douleur avant et apres le geste, les medecins surestimant la douleur avant et apres le geste. Conclusion Les douleurs induites par une PI ou une I sont frequentes, aussi intenses et frequentes au genou qu’au rachis, favorisees par le niveau d’anxiete, le vecu d’un geste anterieur et la douleur dans la semaine precedente. Une prise en compte de ces elements est indispensable.