Juan V. Luciano

Localized 1H-NMR spectroscopy in patients with fibromyalgia: a controlled study of changes in cerebral glutamate/glutamine, inositol, choline, and N-acetylaspartate

IntroductionThe purpose of this study was to investigate whether single-voxel (SV) proton magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), and diffusion tensor imaging (DTI) detected differences between fibromyalgia (FM) patients and healthy controls. We also searched for correlations between neuroimaging abnormalities and neuropsychological variables.MethodsTen patients with FM and 10 gender- and age-matched control subjects were studied. A neuropsychological examination, DWI, DTI, and proton MRS were performed on the brain areas known to be associated with pain processing.ResultsCompared with healthy controls, FM patients had significantly higher levels of glutamate + glutamine (Glx) (mean ± SD, 10.71 ± 0.50 arbitrary institutional units versus 9.89 ± 1.04; P = 0.049) and higher glutamate + glutamine/creatine (Glx/Cr) ratios (1.90 ± 0.12 versus 1.72 ± 0.23; P = 0.034) in the posterior gyrus. Myoinositol (Ins) levels of the right and left hippocampi were significantly lower in FM patients (4.49 ± 0.74 versus 5.17 ± 0.62; P = 0.008 and 4.91 ± 0.85 versus 6.09 ± 0.78; P = 0.004, respectively). In FM patients, decreased myoinositol/creatine (Ins/Cr) ratios were found in the left sensorimotor area (P = 0.05) and the left hippocampus (P = 0.002) and lower levels of choline (P = 0.019) and N-acetyl aspartate + N-acetyl aspartyl glutamate (NAA + NAG) (P = 0.034) in the left hippocampus. Significant correlations between depression, pain, and global function and the posterior gyrus Glx levels and Glx/Cr ratios were observed.ConclusionsGlx within the posterior gyrus could be a pathologic factor in FM. Hippocampal dysfunction may be partially responsible for the depressive symptoms of FM. Additional studies with larger samples are required to confirm these preliminary data.

Psychometric properties of the twelve item World Health Organization Disability Assessment Schedule II (WHO-DAS II) in Spanish primary care patients with a first major depressive episode

BACKGROUND Psychometric information on the World Health Organization Disability Assessment Schedule II (WHO-DAS II) in depressive primary care (PC) patients is scarce and has been obtained with the 36-item version of the instrument. The main objective of this study was to analyse the dimensionality, internal consistency and construct validity of the 12-item WHO-DAS II in a large sample of Spanish PC patients with a first diagnosed major depressive episode. METHOD Data were collected between December 2006 and July 2007. A total of 3615 adult (18 years or older) PC patients from 17 regions of Spain with a first diagnosed major depressive episode participated in the study. The 12-item WHO-DAS II and a battery of instruments assessing sociodemographic characteristics, depression severity (PHQ-9), quality of life (EQ-5D) and chronic health conditions were administered by the family physician during the consultation. RESULTS The principal component analysis and the subsequent confirmatory factor analysis indicated that the 12-item WHO-DAS II is one-dimensional. The instrument showed adequate internal consistency (alpha=0.89) and construct validity because it was significantly associated with quality of life and depression severity (convergent validity) and was able to discriminate between patients on sick leave and those that were working (discriminative validity). LIMITATIONS The test-retest reliability and sensitivity to change of the instrument was not examined due to the cross-sectional design of the study. CONCLUSIONS The 12-item WHO-DAS II is a reliable, valid and useful tool for assessing overall disability in PC patients with depression.

Perceived injustice in fibromyalgia: Psychometric characteristics of the Injustice Experience Questionnaire and relationship with pain catastrophising and pain acceptance

OBJECTIVE To validate a Spanish version of the Injustice Experience Questionnaire (IEQ), a measure of perceived injustice, in a fibromyalgia sample and to examine its relationship with pain catastrophising and pain acceptance. METHODS The IEQ was administered along with the Pain Visual Analogue Scale, the Fibromyalgia Impact Questionnaire, the Hospital Anxiety and Depression Scale, the Pain Catastrophizing Scale (PCS) and the Chronic Pain Acceptance Questionnaire (CPAQ) to 250 primary care patients with fibromyalgia. RESULTS The IEQ had good test-retest reliability (intraclass correlation coefficient=0.98) and internal consistency (Cronbachs α=0.92). The factor structure obtained was similar to the original validation study. The multiple regression analyses showed that perceived injustice (PI) accounted for significant pain-related outcomes after controlling pain intensity, PCS and CPAQ. Principal component analysis of both the IEQ and the CPAQ taken together showed that the two constructs do not represent opposite extremes of the same dimension. CONCLUSION The IEQ is a reliable assessment tool for measuring PI among patients with fibromyalgia. PI seems to be distinct from catastrophising, although the two constructs are very similar. The factor analysis showed that PI and acceptance represent related constructs, and this entails relevant implications for therapy, as acceptance-based interventions would be appropriate.

Effectiveness of group acceptance and commitment therapy for fibromyalgia: a 6-month randomized controlled trial (EFFIGACT study).

Summary Acceptance and commitment therapy is effective for improving several clinical outcomes in fibromyalgia patients ABSTRACT In the last decade, there has been burgeoning interest in the effectiveness of third‐generation psychological therapies for managing fibromyalgia (FM) symptoms. The present study examined the effectiveness of acceptance and commitment therapy (ACT) on functional status as well as the role of pain acceptance as a mediator of treatment outcomes in FM patients. A total of 156 patients with FM were enrolled at primary health care centers in Zaragoza, Spain. The patients were randomly assigned to a group‐based form of ACT (GACT), recommended pharmacological treatment (RPT; pregabalin + duloxetine), or wait list (WL). The primary end point was functional status (measured with the Fibromyalgia Impact Questionnaire, FIQ). Secondary end points included pain catastrophizing, pain acceptance, pain, anxiety, depression, and health‐related quality of life. The differences between groups were calculated by linear mixed‐effects (intention‐to‐treat approach) and mediational models through path analyses. Overall, GACT was statistically superior to both RPT and WL immediately after treatment, and improvements were maintained at 6 months with medium effect sizes in most cases. Immediately after treatment, the number needed to treat for 20% improvement compared to RPT was 2 (95% confidence interval 1.2–2.0), for 50% improvement 46, and for achieving a status of no worse than mild impaired function (FIQ total score <39) also 46. Unexpectedly, 4 of the 5 tested path analyses did not show a mediation effect. Changes in pain acceptance only mediated the relationship between study condition and health‐related quality of life. These findings are discussed in relation to previous psychological research on FM treatment.

The 12-item World Health Organization Disability Assessment Schedule II (WHO-DAS II): a nonparametric item response analysis

BackgroundPrevious studies have analyzed the psychometric properties of the World Health Organization Disability Assessment Schedule II (WHO-DAS II) using classical omnibus measures of scale quality. These analyses are sample dependent and do not model item responses as a function of the underlying trait level. The main objective of this study was to examine the effectiveness of the WHO-DAS II items and their options in discriminating between changes in the underlying disability level by means of item response analyses. We also explored differential item functioning (DIF) in men and women.MethodsThe participants were 3615 adult general practice patients from 17 regions of Spain, with a first diagnosed major depressive episode. The 12-item WHO-DAS II was administered by the general practitioners during the consultation. We used a non-parametric item response method (Kernel-Smoothing) implemented with the TestGraf software to examine the effectiveness of each item (item characteristic curves) and their options (option characteristic curves) in discriminating between changes in the underliying disability level. We examined composite DIF to know whether women had a higher probability than men of endorsing each item.ResultsItem response analyses indicated that the twelve items forming the WHO-DAS II perform very well. All items were determined to provide good discrimination across varying standardized levels of the trait. The items also had option characteristic curves that showed good discrimination, given that each increasing option became more likely than the previous as a function of increasing trait level. No gender-related DIF was found on any of the items.ConclusionsAll WHO-DAS II items were very good at assessing overall disability. Our results supported the appropriateness of the weights assigned to response option categories and showed an absence of gender differences in item functioning.

Validation of the Spanish version of the Chronic Pain Acceptance Questionnaire (CPAQ) for the assessment of acceptance in fibromyalgia

BackgroundThe aim of this study was to validate a Spanish version of the Chronic Pain Acceptance Questionnaire (CPAQ). Pain acceptance is the process of giving up the struggle with pain and learning to live a worthwhile life despite it. The Chronic Pain Acceptance Questionnaire (CPAQ) is the questionnaire most often used to measure pain acceptance in chronic pain populations.MethodsA total of 205 Spanish patients diagnosed with fibromyalgia syndrome who attended our pain clinic were asked to complete a battery of psychometric instruments: the Pain Visual Analogue Scale (PVAS) for pain intensity, the Hospital Anxiety and Depression Scale (HADS), the Medical Outcome Study Short Form 36 (SF-36), the Pain Catastrophising Scale (PCS) and the Fibromyalgia Impact Questionnaire (FIQ).ResultsAnalysis of results showed that the Spanish CPAQ had good test-retest reliability (intraclass correlation coefficient 0.83) and internal consistency reliability (Cronbachs α: 0.83). The Spanish CPAQ score significantly correlated with pain intensity, anxiety, depression, pain catastrophising, health status and physical and psychosocial disability. The Scree plot and a Principal Components Factor analysis confirmed the same two-factor construct as the original English CPAQ.ConclusionThe Spanish CPAQ is a reliable clinical assessment tool with valid construct validity for the acceptance measurement among a sample of Spanish fibromyalgia patients. This study will make it easier to assess pain acceptance in Spanish populations with fibromyalgia.

Burden of chronic physical conditions and mental disorders in primary care

BACKGROUND The World Health Organization (WHO) has stated that the three leading causes of burden of disease in 2030 are projected to include HIV/AIDS, unipolar depression and ischaemic heart disease. AIMS To estimate health-related quality of life (HRQoL) and quality-adjusted life-year (QALY) losses associated with mental disorders and chronic physical conditions in primary healthcare using data from the diagnosis and treatment of mental disorders in primary care (DASMAP) study, an epidemiological survey carried out with primary care patients in Catalonia (Spain). METHOD A cross-sectional survey of a representative sample of 3815 primary care patients. A preference-based measure of health was derived from the 12-item Short Form Health Survey (SF-12): the Short Form-6D (SF-6D) multi-attribute health-status classification. Each profile generated by this questionnaire has a utility (or weight) assigned. We used non-parametric quantile regressions to model the association between both mental disorders and chronic physical condition and SF-6D scores. RESULTS Conditions associated with SF-6D were: mood disorders, beta = -0.20 (95% CI -0.18 to -0.21); pain, beta = -0.08 (95%CI -0.06 to -0.09) and anxiety, beta = -0.04 (95% CI -0.03 to -0.06). The top three causes of QALY losses annually per 100 000 participants were pain (5064), mood disorders (2634) and anxiety (805). CONCLUSIONS Estimation of QALY losses showed that mood disorders ranked second behind pain-related chronic medical conditions.

Effectiveness of cognitive behaviour therapy for the treatment of catastrophisation in patients with fibromyalgia: a randomised controlled trial

IntroductionNo randomised, controlled trials have been conducted to date on the efficacy of psychological and pharmacological treatments of pain catastrophising (PC) in patients with fibromyalgia. Our aim in this study was to assess the effectiveness of cognitive-behaviour therapy (CBT) and the recommended pharmacological treatment (RPT) compared with treatment as usual (TAU) at the primary care level for the treatment of PC in fibromyalgia patients.MethodsWe conducted a six-month, multicenter, randomized, blinded, parallel group, controlled trial in which patients were randomly assigned to one of three study arms: CBT (n = 57), RPT (n = 56) and TAU at the primary care level (n = 56). The major outcome of this study was PC in patients with fibromyalgia. The secondary variables were pain acceptance, depression, anxiety, pain, global function and quality of life.ResultsCBT significantly decreased global PC at the six-month follow-up examination with effect sizes of Cohens d = 0.73 and 1.01 compared with RPT and TAU, respectively. CBT was also more effective than RPT and TAU at increasing pain acceptance at the six-month follow-up examination (effect sizes of Cohens d = 0.77 and 0.80, respectively). Compared with RPT and TAU, CBT was more effective at improving global function based on the Fibromyalgia Impact Questionnaire (six-month effect sizes Cohens d = 0.44 and 0.53, respectively) and quality of life based on the European Quality of Life Scale (six-month effect sizes Cohens d = 0.11 and 0.40, respectively). There were no differences among the three treatments with regard to pain and depression.ConclusionsCBT shows higher efficacy than RPT and TAU not only in key outcomes in FM, such as function and quality of life, but also in relevant mediators of treatment effects, such as pain catastrophising and pain acceptance.Trial registrationISRCTN: ISRCTN10804772

Confirmatory Factor Analysis of the White Bear Suppression Inventory and the Thought Control Questionnaire

The White Bear Suppression Inventory (WBSI) was developed to assess chronic thought suppression, whereas the Thought Control Questionnaire (TCQ) measures different strategies to suppress unpleasant intrusive thoughts. The present study examines the latent factor structure of these instruments in a sample of 540 normal subjects using confirmatory factor analyses (CFA). Regarding the WBSI, the CFAs indicated that the tested models did not provide a good fit for the data. Data analysis showed that the TCQ with five factors and 30 items did not reach a reasonable fit. Therefore, in order to present a five-factor structure with an adequate fit, those items with problematic factor loadings were eliminated. Correlational analyses indicated that the WBSI had a significant association with depression, obsessive-compulsive symptoms, and pathological worry, whereas only two TCQ subscales, punishment and worry, were related to these psychopathological symptoms.

Effectiveness of a psychoeducational treatment program implemented in general practice for fibromyalgia patients: a randomized controlled trial.

ObjectivesA recent meta-analysis concluded that multicomponent treatments are effective for some fibromyalgia (FM) symptoms. The objective of this study was to examine whether a psychoeducational intervention implemented in primary care is more effective than usual care for improving the functional status of patients with FM. MethodsThis study was based on a randomized controlled trial. The 484 patients with FM included in a database of the Viladecans Hospital (Barcelona, Spain) were eligible for screening. Finally, 108 patients were randomly assigned to the intervention and 108 patients were assigned to usual care. The intervention comprised nine 2-hour sessions (5 sessions of education and 4 sessions of autogenic relaxation). The patients were assessed before and after the intervention with a battery of instruments (measuring sociodemographic data, medical comorbidities, functional status, trait anxiety, and social desirability). ResultsThe posttreatment drop-out rate was 9.7% (intervention: 6.5%; control: 13%). The intention-to-treat analyses showed significant differences between the groups at posttreatment: the intervention group improved in physical impairment, days not feeling well, pain, general fatigue, morning fatigue, stiffness, anxiety, and depression (medium effect size in most cases). The patients who responded to the intervention reported less trait anxiety at baseline than nonresponders. The absolute risk reduction with the intervention was 36.1% (95% confidence interval: 23.3-48.8) and the number needed to treat was 3 (95% confidence interval: 2.0-4.3). DiscussionA 2-month psychoeducational intervention improves the functional status of FM patients to a greater extent than usual care, at least in the short-term. The social desirability bias did not explain the reported outcomes. Trait anxiety was associated with response to treatment. Trial RegistrationNCT00550966.