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The aim of this study was to evaluate the psychometric properties of the Danish version of the Fibromyalgia Impact Questionnaire - Revised (FIQR), when used to quantify the severity of disease burden in a Danish population of patients with chronic widespread pain (CWP), including fibromyalgia (FM).A total of 924 participants diagnosed with CWP and/or FM completed an electronic version of the FIQR via touchscreens in the clinic at referral for specialist care. Data were collected from 1 January 2018 to 3 September 2020. Rasch measurement methods were applied.Rating scale analysis suggested multiple threshold disordering in the 0-10 category rating scale. A principal component analysis suggested assessment of a multidimensional construct. Thus, the Rasch analysis of the full FIQR was discontinued. Instead, Rasch analyses were performed on the two subscales: 'function' and 'symptoms'. By collapsing the rating scale to a 0-4 category scale, the remaining threshold disordering of both subscale was solved. Only the symptom subscale indicated multidimensionality. There was underfitting misfit of item 21 and overfitting misfit of item 12. No significant differential item functioning, defined by sex, ethnicity, or education, was found.The FIQR should be considered as an instrument consisting of three separate subscales representing 'function', 'overall impact', and 'symptoms'. We recommend calculating and reporting on both a 0-10 and a 0-4 category scale. Also, if using the total FIQR score as an outcome measure, this should be done with caution, until revision of the rating scale.

Research into the neurobiological and psychosocial mechanisms involved in fibromyalgia has progressed remarkably in recent years. Despite this, current accounts of fibromyalgia fail to capture the complex, dynamic, and mutual crosstalk between neurophysiological and psychosocial domains. We conducted a comprehensive review of the existing literature in order to: a) synthesize current knowledge on fibromyalgia; b) explore and highlight multi-level links and pathways between different systems; and c) build bridges connecting disparate perspectives. An extensive panel of international experts in neurophysiological and psychosocial aspects of fibromyalgia discussed the collected evidence and progressively refined and conceptualized its interpretation. This work constitutes an essential step towards the development of a model capable of integrating the main factors implicated in fibromyalgia into a single, unified construct which appears indispensable to foster the understanding, assessment, and intervention for fibromyalgia.

Covariate adjustment is often used in statistical analysis of randomized experiments to increase efficiency of estimators of treatment effects. In this paper, we study covariate adjustment based on the empirical and Euclidean likelihoods, and propose weighted versions that arise as natural alternatives. The weighted methods incorporate the auxiliary information that the covariates have equal means among the treatment groups due to randomization. We show that the empirical and the Euclidean likelihoods and their weighted versions are first order equivalent to Koch’s nonparametric covariance adjustment. Allowing the weights to be negative, the resulting pseudo Euclidean likelihood is equivalent to Koch’s method, and its weighted version can be viewed as a weighted version of Koch’s method. In a simulation study, we assess the finite sample properties of the proposed methods. The analysis of a clinical trial data set illustrates an application of these methods to a practical situation.

To evaluate the relationship between self-reported and performance-based measures of functioning in rheumatoid arthritis (RA), knee osteoarthritis (OA), and fibromyalgia (FM), and the influence of pain and fatigue.Self-reported functioning was assessed by the Stanford Health Assessment Questionnaire, Fibromyalgia Impact Questionnaire, and Knee injury and Osteoarthritis Outcome Score. Performance-based measures of task-related physical activity included grip strength and Six-Minute Walk Test (6MWT). Assessment of Motor and Process Skills (AMPS) was used to obtain performance-based measures of activities of daily living (ADL) ability. Pain and fatigue were assessed by 100 mm visual analogue scales. Spearman's rho correlation and regression modelling were applied.Correlations between self-reported functioning and performance-based measures of ADL ability were weak to moderate, and strongest in OA (r = 0.57, p = 0.002), and AMPS ADL ability measures did not enter regression models as explanatory factors for self-reported functioning. Correlations between AMPS ADL ability measures and measures of task-related physical activity were weak, except for a strong correlation between AMPS ADL motor ability and 6MWT in OA (r = 0.63, p = 0.000). The 6MWT was the only performance-based test explaining variance in AMPS motor ability (OA = 42%; FM = 11%). Pain explained variance in self-reported ability and contributed to variance in AMPS ADL motor ability measures in OA.Self-reported and observed measures of functioning assess partly different aspects of functioning, and both approaches may therefore be relevant in a structured assessment of patients with musculoskeletal disorders.

OBJECTIVE: To study the prognostic value of widespread pain and of musculoskeletal ultrasound (US) examination for subsequent treatment outcomes in patients with psoriatic arthritis (PsA).METHODS: An exploratory prospective cohort study enrolled patients with PsA initiating biologic or conventional synthetic disease-modifying antirheumatic drugs in routine care. Clinical, US, and patient-reported measures were collected at baseline and after 4 months. Widespread nonarthritic pain (WP) was defined as a Widespread Pain Index score of ≥4 with pain in ≥4 of 5 regions. PsA activity by US was defined as color Doppler (yes/no) in selected entheses, joints, or tendons. The main response criteria included the American College of Rheumatology 20% improvement, the Disease Activity in Psoriatic Arthritis 50% improvement, and minimal disease activity. The primary analyses were age- and sex-adjusted logistic regression.RESULTS: WP was present in 24 of 69 included patients (35%) and was associated with worse patient-reported and composite baseline measures, while US and other objective findings were similar to those in patients without WP. The odds of reaching minimal disease activity after 4 months were significantly greater for patients enrolled without WP (odds ratio 18.43 [95% confidence interval 1.51, 224.41]; P = 0.022), while WP did not impair other response measures. Patients with baseline color Doppler activity (n = 42 [61%]) had a worse objective PsA burden, but their chance of treatment response was comparable to those without color Doppler.CONCLUSION: More than one-third of patients with PsA presented with WP, which was associated with worse patient-reported scores and failure to achieve minimal disease activity following conventional synthetic or biologic disease-modifying antirheumatic drug therapy. PsA activity by color Doppler US had no influence on subsequent treatment response in this PsA cohort.

Background Low-dose naltrexone (LDN) is used widely as an off-label treatment for pain despite limited evidence for its effectiveness. A few small trials with a high risk of bias have investigated the effect of LDN on pain associated with fibromyalgia in women, but larger and more methodologically robust studies are needed. The primary aim of this randomized controlled trial is to investigate if 12 weeks of LDN treatment is superior to placebo in reducing the average pain intensity during the last 7 days in women with fibromyalgia. Methods A single-center, permuted block randomized, double-blind, placebo-controlled, parallel-group trial will be performed in Denmark. Randomization comprises 100 women aged 18–64 years diagnosed with fibromyalgia who will be treated with either LDN or placebo for 12 weeks including a 4-week titration phase. The primary outcome is change in average pain intensity (during the last 7 days) from baseline to 12 weeks. Secondary outcomes are other fibromyalgia-related symptoms, i.e., tenderness, fatigue, sleep disturbance, stiffness, memory problems, depression, anxiety and measures of global assessment, physical function, impact of fibromyalgia, pain distribution, and health-related quality of life. Intention-to-treat analysis will be performed, and the number of responders with a more than 15%, 30%, and 50% improvement of pain after 12 weeks will be calculated for the LDN and placebo groups. Exploratory outcomes include measures of pain sensitivity, muscle performance, and biomarkers. Discussion This study will contribute with high-level evidence on the efficacy of low-dose naltrexone for the treatment of pain in women with fibromyalgia. Secondary outcomes include both disease-specific and generic components investigating whether LDN influences other symptoms than pain. Explorative outcomes are included to provide greater insight into the mechanism of action of LDN and possibly a better understanding of the underlying pathology in fibromyalgia. Trial registration EudraCT 2019-000702-30. Registered on 12 July 2019. ClinicalTrials.gov NCT04270877. Registered on 17 February 2020

Introduction: The association between chronic widespread pain (CWP) and disability is well established. Although research support large interindividual differences in functional outcomes, limited studies are available on the socio-economic consequences of offering stratified treatment based on prognostic factors. Identification of predictors of long-term functional outcomes such as work disability as a critical consequence, could assist early and targeted personalised interventions. The primary objective of this cohort study is to identify prognostic factors for the primary endpoint work status (employed and working vs not working) in patients with CWP assessed 3 years from baseline, that is, at referral for specialist care.Methods and analyses: Data are collected at the diagnostic unit at Department of Rheumatology, Frederiksberg Hospital. The first 1000 patients ≥18 years of age registered in a clinical research database (DANFIB registry) with CWP either ‘employed and working’ or ‘not working’ will be enrolled. Participants must meet the American College of Rheumatology 1990 definition of CWP, that is, pain in all four body quadrants and axially for more than 3 months and are additionally screened for fulfilment of criteria for fibromyalgia. Clinical data and patient-reported outcomes are collected at referral (baseline) through clinical assessment and electronic questionnaires. Data on the primary endpoint work status at baseline and 3 years from baseline will be extracted from the Integrated Labour Market Database, Statistics Denmark and the nationwide Danish DREAM database. Prognostic factor analysis will be based on multivariable logistic regression modelling with the dichotomous work status as dependent variable.Ethics and dissemination: Sensitive personal data will be anonymised according to regulations by the Danish Data Protection Agency, and informed consent are obtained from all participants. Understanding and improving the prognosis of a health condition like CWP should be a priority in clinical research and practice. Results will be published in international peer-reviewed journals. Introduction The association between chronic widespread pain (CWP) and disability is well established. Although research support large interindividual differences in functional outcomes, limited studies are available on the socio-economic consequences of offering stratified treatment based on prognostic factors. Identification of predictors of long-term functional outcomes such as work disability as a critical consequence, could assist early and targeted personalised interventions. The primary objective of this cohort study is to identify prognostic factors for the primary endpoint work status (employed and working vs not working) in patients with CWP assessed 3 years from baseline, that is, at referral for specialist care. Methods and analyses Data are collected at the diagnostic unit at Department of Rheumatology, Frederiksberg Hospital. The first 1000 patients ≥18 years of age registered in a clinical research database (DANFIB registry) with CWP either employed and working' or not working' will be enrolled. Participants must meet the American College of Rheumatology 1990 definition of CWP, that is, pain in all four body quadrants and axially for more than 3 months and are additionally screened for fulfilment of criteria for fibromyalgia. Clinical data and patient-reported outcomes are collected at referral (baseline) through clinical assessment and electronic questionnaires. Data on the primary endpoint work status at baseline and 3 years from baseline will be extracted from the Integrated Labour Market Database, Statistics Denmark and the nationwide Danish DREAM database. Prognostic factor analysis will be based on multivariable logistic regression modelling with the dichotomous work status as dependent variable. Ethics and dissemination Sensitive personal data will be anonymised according to regulations by the Danish Data Protection Agency, and informed consent are obtained from all participants. Understanding and improving the prognosis of a health condition like CWP should be a priority in clinical research and practice. Results will be published in international peer-reviewed journals. Trial registration number NCT04862520.

Aims and objectives To describe how group-based multidisciplinary rehabilitation for patients with fibromyalgia can influence patients' self-efficacy and ability to cope with their illness. Background Multidisciplinary rehabilitation is recommended in the management of fibromyalgia. Self-efficacy is said to influence and predict adaptive coping behaviours and functioning. However, knowledge is lacking on how rehabilitation programmes may influence self-efficacy and ability to cope, from the patients' perspective. Design Grounded theory study of semi-structured focus group interviews. Methods Participants (n = 17) were included in four focus groups that had completed a two-week multidisciplinary rehabilitation programme together. Interviews were conducted four weeks after each group had completed the programme. The analysis was conducted constant comparatively applying open, axial and selective coding. Results Categories (in italics) were derived from data in which the explanatory core category was identified: Learning to accept and live with pain as a life condition, and linked to three categories mutually influencing each other: Increased self-acceptance of living with the illness, experiencing acceptance from others and developing new coping strategies. Thus, patients benefitted from multidisciplinary rehabilitation with stronger self-efficacy and expectations to their future coping. However, limitations in the programme were identified, as the programme was short and intensive with no subsequent follow-up, and social welfare was not sufficiently addressed. Participants also found it difficult to maintain knowledge and were lacking individual sessions with the psychologist and had waited long to receive rehabilitation. Conclusion Multidisciplinary rehabilitation may advantageously be offered to patients with fibromyalgia. However, earlier action with longer programmes, in which patients' social situation is addressed, comprising individual sessions with the psychologist, with multiple repetitions of the content and follow-up sessions, may further enhance the patients' self-efficacy and coping with their illness.

Introduction:. Survivors of torture are for many reasons at particularly high risk for inadequate assessment and management of pain. Among the many health problems associated with torture, persistent pain is frequent, particularly pain in the musculoskeletal system. The pathophysiology underlying post-torture pain is largely unknown, but pain inflicted in torture may have profound effects on neurophysiology and pain processing. Methods:. A narrative review of assessment and treatment studies, informed by clinical experience, was undertaken. Results:. The clinical presentation in survivors of torture shares characteristics with other chronic primary pain syndromes, including chronic widespread pain. Unfortunately, such pain is often misunderstood and dismissed as a manifestation of psychological distress, both in specialist psychosocially oriented torture services and in mainstream health care. This means that pain is at risk of not being recognized, assessed, or managed as a problem in its own right. Conclusions:. The available research literature on rehabilitation for torture survivors is predominantly targeted at mental health problems, and studies of effectiveness of pain management in torture survivors are lacking. Rehabilitation is identified as a right in the UN Convention on Torture, aiming to restore as far as possible torture survivors' health and capacity for full participation in society. It is therefore important that pain and its consequences are adequately addressed in rehabilitative efforts. This article summarizes the current status on assessment and management of pain problems in the torture survivor.

Objective: To evaluate the benefit of adding occupational therapy or physiotherapy interventions to a standard rehabilitation programme targeted for chronic widespread pain. Design: Randomized active-controlled non-blinded trial. Subjects: Women with chronic widespread pain recruited in a tertiary outpatient clinic. Methods: Participants were randomized to a two-week, group-based standard rehabilitation programme followed by 16 weeks of group-based occupational therapy (Group BOT, n = 43) or 16 weeks of group-based physiotherapy (Group BPT, n = 42). Group A only received the two-week rehabilitation programme acting as comparator ( n = 96). Outcomes: Primary outcomes were the Assessment of Motor and Process Skills and Short Form-36 (SF36) Mental Component Summary score. Results: Mean changes in motor and process ability measures were clinically and statistically insignificant and without differences across the three groups assessed 88 weeks from baseline. Motor ability measures: −0.006 (95% confidence interval (CI): −0.244 to 0.233) in Group BOT; −0.045 (95% CI: −0.291 to 0.202) in Group BPT; and −0.017 (95% CI: −0.248 to 0.213) in Group A, P = 0.903. Process ability measures: 0.087 (95% CI: −0.056 to 0.231) in Group BOT; 0.075 (95% CI: −0.075 to 0.226) in Group BPT; and 0.072 (95% CI: −0.067 to 0.211) in Group A, P = 0.924. Mean changes in patient-reported outcomes were likewise small; clinically and statistically insignificant; and independent of group allocation, except for the SF36 mental component summary score in the BPT group: 8.58 (95% CI: 1.75 to 15.41). Conclusion: Participants were on average stable in observation-based measures of functional ability and patient-reported outcomes, except in overall mental well-being, favouring the enhanced intervention. Efficacy of additional interventions on functional ability remains uncertain.

Background Pain is a major concern for patients with psoriatic arthritis (PsA) in spite of treatment with biologic/conventional disease modifying drugs (b/csDMARDS). Studies on the prognostic role of pain mechanisms in PsA, are scarce. Objectives To investigate the presence of widespread non-arthritic pain (WP) in patients with PsA, and determine its relation to patient-reported, clinical- and ultrasound (US) disease measures, as well as to achievement of 4 months response to b/csDMARD therapy. Secondly, to study if US Colour Doppler activity (CD) at baseline is associated to treatment response. Methods A prospective cohort study was performed following a protocol.1Patients initiating b/csDMARDs for PsA were recruited from rheumatology clinics in Copenhagen. Clinical- and US examinations and patient-reported outcomes (PROs) were performed at baseline and after 4 months. WP was defined as a Widespread Pain Index≥4, and pain in ≥4/5 regions. CD activity in selected joints, entheses and tendons (73 projections) was summed. Response was assessed by American College of Rheumatology 20% (ACR20), Disease Activity in Psoriatic Arthritis 50% (DAPSA 50) and Minimal Disease Activity (MDA). Main response analyses were based on intention to treat with non-responder imputation, and consisted of logistic regressions adjusting for gender and age. Results Of 123 screened patients, 69 were included. Of these, 24 (35%) fulfilled the WP definition. At baseline (Table), WP was associated with worse PROs and composite scores, while CD activity and clinical measures were similar to those without WP. WP profile was significantly related to achievement of MDA at follow-up but not to other response criteria (table 1). Presence of CD activity at baseline was not significantly associated to 4 months response by any criteria, e.g. 19%/31% with CD=0/CD >0, reached ACR20, (p=0.262). Conclusions WP was present in 1/3 of patients, and associated with worse PROs, composite measures, and failure to achieve MDA at follow-up. Neither WP nor CD at baseline was related to other response measures. Reference Hojgaardet al. BMJ Open2006;6. doi:10.1136/bmjopen-2015-010650 Acknowledgements Thanks to: The Oak foundation, Danish Rheumatism Association, Centre for Rheumatology Gentofte Hospital. Disclosure of Interest None declared

Background: Assessment of depression in chronic pain patients by self-rating questionnaires developed and validated for use in normal and/or psychiatric populations is common. The aim of this study was to evaluate the psychometric properties of the Major Depression Inventory (MDI) in a sample of females with chronic widespread pain (CWP).Method: A total of 263 females diagnosed with CWP and referred for rehabilitation completed the MDI as part of the baseline evaluation. Rasch analysis was applied to this dataset. Rasch measurement models allow detailed analyses of an instruments rating scale and further aspects of validity, including fit of individual scale items to a unidimensional model indicating assessment of a single construct (depression), as a prerequisite for measurement.Results: The Rasch analysis revealed substantial problems with the rating scale properties of the MDI and lack of unidimensionality. In contrast to somatic items, MDI items related to depressed mood and negative view of oneself were distributed at the higher end of the item difficulty measurement scale, indicating low endorsement of these items.Discussion: From the perspective of the Rasch measurement model, the MDI demonstrated insufficient psychometric properties when used to identify and quantify severity of depression in a clinical sample of females with CWP. The observed item endorsement pattern indicated that, in this study population, the relatively high depression severity scores primarily pertained to a common core of pain-related somatic symptoms. Careful consideration when interpreting questionnaire-derived scores of depression implemented in research and routine clinical care of patients with chronic pain is warranted.

To assess the association between physical fitness and fibromyalgia (FM) severity in women with FM as well as to assess whether different fitness components present an independent relation with FM severity.Population-based cross-sectional study.University facilities and FM associations.Women with FM (N=444).Not applicable.FM severity was assessed with the Revised Fibromyalgia Impact Questionnaire (FIQR). Aerobic fitness (6-min walk test), muscle strength (handgrip, chair stand, and arm curl tests), flexibility (chair sit and reach and back scratch tests), and motor agility (8 foot Up and Go test) were measured with the Senior Fitness Test battery and digital dynamometry. A standardized composite score (hereafter "global fitness profile") was calculated and divided into quintiles.Overall, physical fitness was significantly associated with the FIQR total and subscale scores, regardless of the fitness test used (all P.05). The 6-minute walk and back-scratch tests were independently associated with the FIQR total score (R(2)=.88; both P.005). The group with the highest global fitness profile had 16% lower FM severity than did the group with the lowest global fitness profile (P.001).Our results suggest that higher physical fitness is consistently associated with lower FM severity in women with FM. Aerobic fitness and flexibility present independent associations with FM severity. However, the FIQR variability explained by these fitness tests was rather low (10%), and further research on the potential disagreement between performance-based physical fitness and different self-reported outcomes in women with FM is warranted.

OBJECTIVES: To compare the 28-joint Disease Activity Score (DAS28) and its components in patients with rheumatoid arthritis (RA) with and without concomitant fibromyalgia (FM), and to investigate the use of biological treatment in the two groups.METHOD: Questionnaires developed to diagnose FM were handed out among RA patients during their planned visits. Values for DAS28 were obtained from the DANBIO registry. Demographic data and data on patients' medical treatment, disease duration, serological and radiological status were retrieved from patients' files. The χ(2) test and an unpaired t-test were applied to investigate group differences in the use of biological therapy, baseline characteristics, patient-reported outcomes, and DAS28 between groups when appropriate.RESULTS: Questionnaires were completed by 162 out of 264 (61%) patients. Twenty-five patients (15.4%) with concomitant FM were identified. No group differences were found regarding disease duration, age, gender, and serological status. Of the RA patients with concomitant FM, 64% were treated with biological therapy vs. 32% of RA patients without concomitant FM (p = 0.002). The mean DAS28 in the FM group was 4.4 compared to 2.9 in the non-FM group (p < 0.001). Elevated DAS28 in the FM group resulted from a high tender joint count (p = 0.003) and a high visual analogue scale (VAS)-global score (p < 0.001). Erosions were more frequent in the non-FM group (p = 0.04).CONCLUSIONS: Concomitant FM in patients with RA is associated with a higher DAS28 due to subjective parameters and with the more frequent use of biological treatments. This raises the question of whether the more frequent use of biologics in these patients is justified by inflammation, or is instead due to persistent pain and other centrally mediated symptoms.

SUMMARY All generalist and specialist clinicians are likely to encounter torture survivors among refugees and asylum seekers. A minority of people survive torture and a smaller minority reach a developed country; those who do tend to be the more resilient and resourceful. They have many health, social and welfare problems; persistent pain in the musculoskeletal system is one of the most common. There is little specific evidence on pain in survivors of torture; the guidelines on interdisciplinary specialist management are applicable. Most of the literature on refugee survivors of torture has an exclusive focus on psychological disorders, with particularly poor understanding of pain problems. This article summarizes the current status of assessment and treatment of pain problems in the torture survivor.

PURPOSE: This study examined the associations of different levels of depression with pain, sleep quality, fatigue, functional exercise capacity, overall fibromyalgia (FM) severity, and health-related quality of life (HRQoL) in women with FM. METHODS: A total of 451 women with FM participated in this cross-sectional study. Depressive symptoms (Beck Depression Inventory; BDI-II), pain intensity (numerical rating scale; NRS), pain sensitivity (algometry), sleep quality (Pittsburgh Sleep Quality Index), fatigue (Multidimensional Fatigue Inventory), functional exercise capacity (6-min walk test), FM severity (revised Fibromyalgia Impact Questionnaire), and HRQoL (SF-36) were assessed. RESULTS: Participants with severe depressive symptoms had significantly higher pain intensity (NRS = 1.1; 95 % CI 0.3-1.8), fatigue (12.6-units; 95 % CI 8.2-17.1) and overall FM severity (12.6-units; 95 % CI 11.4-23.7), as well as poorer sleep quality (3.2-units; 95 % CI 1.7-4.7) and mental component of HRQoL (-17.0-units; 95 % CI -21.0 to -12.9) than participants with minimal signs of depression. There was no association of signs of depression with pain sensitivity, exercise capacity, or the physical component of HRQoL (P > 0.05). CONCLUSIONS: These results extend current knowledge on the association of signs of depression with FM severity and quality of life in women with FM, and suggest that severity of depressive symptoms could potentially be a prognostic factor to be considered in future prospective intervention studies.

Background Fatigue has been identified as one of the most significant symptoms and an outcome of great importance to patients with psoriatic arthritis (PsA), but the association between underlying components of experienced fatigue and the disease has been sparsely investigated. [1] Objectives To describe the degree of fatigue in a PsA population. Secondly, to explore which components of inflammation and non-inflammatory factors contribute to experienced fatigue. Methods The study was designed as a cross-sectional survey including patients registered in DANBIO, the Danish nationwide rheumatologic registry, from December 2013 to June 2014. Principal component analysis was used to identify clustering factors associated with fatigue Results A total of 1,062 PsA patients were included in the study. The median Visual Analog Scale (VAS) fatigue score was 57mm. Patients with moderate to severe fatigue (VAS score ≥57) had higher scores of pain, DAS28, HAQ, patient global assessment, and more tender and swollen joints (p Conclusions Clinical inflammatory disease activity, chronification, as well as pain in the absence of inflammation were all identified as important factors explaining 63% of moderate to severe fatigue in the current PsA population. References Orbai AM, Mease PJ, de WM et al. Report of the GRAPPA-OMERACT Psoriatic Arthritis Working Group from the GRAPPA 2015 Annual Meeting. J Rheumatol 43; 965–9. Acknowledgements This study was supported by the Oak Foundation. Data was extracted from the DANBIO Registry. Disclosure of Interest M. Skougaard: None declared, T. Jorgensen Speakers bureau: Abbvie, Roche, UCB, Novartis, Biogen, S. Rifbjerg-Madsen: None declared, L. Coates Grant/research support from: Abbvie, BMS, Celgene, Jannsen Pharmaceuticals, Lilly, MSD, Novartis, Pfizer, Sun Pharma, UCB, A. Egeberg Grant/research support from: Pfizer, Eli Lilly, Speakers bureau: Pfizer, Eli Lilly, Novartis, Galderma, Janssen Pharmaceuticals, K. Amris: None declared, L. Dreyer: None declared, P. Hojgaard Speakers bureau: Celgene, UCB, J. Guldberg-Moller Paid instructor for: Abbvie, J. Merola Grant/research support from: Biogen IDEC, Amgen, Pfizer, Boehringer Ingelheim, Consultant for: Biogen IDEC, Eli Lilly, Novartis, Momenta, UCB, Kiniksa, AbbVie, Amgen, Pfizer, Janssen Pharmaceuticals, Momenta, Mallinckrodt, Speakers bureau: AbbVie, Eli Lilly, P. Frederiksen: None declared, H. Gudbergsen Speakers bureau: MSD, Pfizer, L. E. Kristensen Speakers bureau: Pfizer, AbbVie, Amgen, UCB, Celgene, BMS, MSD, Novartis, Eli Lilly, Janssen Pharmaceuticals.

The EULAR recommendations for the management of fibromyalgia are based on more than 100 reviews and meta-analyses of individual therapies and medicines.1 Thus, the quality of the evidence in making recommendations on effectiveness and efficacy is generally very high. In contrast, there is little published research …

Objective: To evaluate the relationships between key outcome variables, classified according to the International Classification of Functioning, Disability and Health (ICF), and observed and self-reported functional ability in patients with chronic widespread pain. Design: Cross-sectional with systematic data collection in a clinical setting. Subjects: A total of 257 consecutively enrolled women with chronic widespread pain. Methods: Multidimensional assessment using self-report and observation-based assessment tools identified to cover ICF categories included in the brief ICF Core Set for chronic widespread pain. Results: Relationships between ICF variables and observed functional ability measured with the Assessment of Motor and Process Skills (AMPS) were few. Out of 36 relationships analysed, only 4 ICF variables showed a moderate correlation with the AMPS motor ability measure. A moderate to strong correlation between numerous ICF variables and self-reported functioning was noted. Multivariate regression modelling supported significant contributions from pain and psychosocial variables to the variability in self-reported functional ability, but not to the variability in AMPS ability measures. Conclusion: Observation-based assessment of functional ability in patients with chronic widespread pain is less influenced by pain and psychosocial factors than are self-reported evaluations. Valid observation-based assessment tools, such as the AMPS, should be included in clinical evaluation and future research addressing functional outcomes in this patient population.

Torture and the conditions under which it is inflicted often leave persistent painful disorders. Because there may be no lasting signs, persistent pain is often misconceived as a somatic representation of psychological distress, also common after torture. This serious failure to understand the nature of persistent pain means that pain is largely overlooked and untreated in torture survivors. We carried out a systematic review on treatments for pain from torture, but found few studies and little use of current understanding and evidence. We discuss this in the context of treating pain associated with psychological distress and of the broader problems faced by the refugee and torture survivor that may take priority over pain. We propose clinical and research implications for this neglected field.

OBJECTIVE: To examine the hypothesis that change in pain self-efficacy is associated with observed and self-reported activity, pain intensity, catastrophizing, and quality of life after multi-disciplinary rehabilitation of fibromyalgia patients.DESIGN: In-depth analyses of secondary outcomes of a randomized-controlled trial.SUBJECTS: Women (N = 187) with fibromyalgia.METHODS: Outcomes were Pain Self-Efficacy, Assessment of Motor and Process Skills (AMPS), SF-36 Physical Function (SF-36-PF), pain intensity, and SF-36 Mental Composite Score (SF-36-MCS) to assess quality of life and pain catastrophizing. Individual and group associations between outcomes were examined.RESULTS: Individual changes in pain self-efficacy were not associated with changes in observed activity: AMPS motor (r s = 0.08, p = 0.27) and process (r s = 0.12, p = 0.11), not even in those patients with a clinically relevant improvement in observed functioning (38.5%), and only weakly or moderatly with changes in SF-36-PF; (r s = 0.31, p CONCLUSION: The main hypothesis was falsified, as there was no association between pain self-efficacy and actual performance of activity. The relation to functioning may be limited to perceived, cognitive-emotional aspects, as indicated by the weak to moderate correlations to the self-reported measures. Implications for Rehabilitation Improvement in observed activity post multi-disciplinary rehabilitation was not associated with change in pain self-efficacy. Patients performed better after rehabilitation, but did not perceive to have improved their capacity. The relationship between pain self-efficacy and functioning may be limited to cognitive-emotional aspects rather than actual activity. Both observational and self-reported measures should be included in evaluating outcomes of rehabilitation for patients with fibromyalgia.

Background: The painDETECT questionnaire (PDQ) is a mechanism-based pain classification tool assigning patients to one of three categories depending on the quality of the experienced pain. Patients with non-nociceptive pain score high on the PDQ. The objective was to assess the proportions of the three PDQ classification groups in patients with rheumatoid arthritis (RA) and to explore differences in clinical characteristics. Method: RA patients initiating or escalating their RA therapy were included prospectively and underwent a thorough examination programme. Low (PDQ score < 13), medium (PDQ score 13–18), and high (PDQ score > 18) scores indicate nociceptive, unclear/possible neuropathic, or neuropathic pain mechanisms, respectively. Results: The 102 included patients were classified into the following PDQ classification groups: low = 65%, medium = 23%, and high = 12%. Patients in the medium and high PDQ groups scored worse on indicators of anxiety, depression, disability, mental health-related quality of life, pain, and fatigue. They also had more tender points and an RA disease activity score based on 28 joints (DAS28) where a higher fraction of the composite score pertained to non-inflammatory factors compared to patients in the low PDQ classification group. There were no differences in objective inflammatory indices across groups. Multiple regression analysis demonstrated that the tender joint count (TJC) and the 36-item Short Form Health Survey (SF36) mental component summary (MCS) score were independently associated with the PDQ score. Conclusions: In patients initiating or intensifying medical treatment for their RA, non-nociceptive pain (PDQ score ≥ 13) is common. In these patients, the pain mechanisms result in increased disease activity scores on a non-inflammatory basis.

Functional ability, including the ability to perform activities of daily living (ADL), is considered a core outcome domain in chronic pain clinical trials and is usually assessed through generic or disease-specific self-report questionnaires. Research, however, indicates that self-report and performance-based assessment of ADL offer distinct but complementary information about ability. The present study, therefore, investigated the applicability of a performance-based measure of ADL ability, the Assessment of Motor and Process Skills (AMPS), among 50 women with chronic widespread pain. The investigated psychometric properties of the AMPS included discrimination between a sample of healthy women and those with chronic widespread pain, as well as stability when no intervention was provided and sensitivity to change following intervention. Data were obtained based on a repeated measures design performing AMPS evaluations twice pre- and twice post-rehabilitation. Results indicated that the ADL motor ability measures of the participants were significantly lower than those of healthy women of same age, the ADL motor and ADL process ability measures remained stable when no intervention was provided and the ADL motor ability measures were sensitive to change following a 2-week interdisciplinary rehabilitation program. A weak correlation ( r s = −0.35) was found between self-reported ADL ability as measured by the physical function subscale of the Functional Impact Questionnaire (FIQ) and performance-based ADL motor measures, and no correlation ( r s = −0.02) was found between FIQ ADL measures and ADL process ability, supporting the need for both performance-based and self-reported assessment of ADL.

In all, 19-22% of the adult Danish population suffer from chronic pain - most frequently in the musculoskeletal system. Different pain management strategies depending on pain mechanism (neuropathic/nociceptive) make diagnosing the pain condition especially important.To investigate whether a validated, self-administered questionnaire (PainDETECT) helps specialists and general practitioners in Denmark identify patients with neuropathic pain components (NeP).In a non-interventional study a sample of Danish specialists (rheumatologists and anaesthesiologists) and general practitioners used the PainDETECT questionnaire on 1322 chronic pain patients. PainDETECT was filled in by patients and scored by the physician. A PainDETECT score above 18 indicates the presence of NeP.A total of 87-95% of the included chronic pain patients (702 by specialists (mean age: 56 years) and 620 by general practitioners (mean age: 55 years)) had musculoskeletal pain. In 39-43% of these patients NeP components were present as assessed by PainDETECT (score 21.1-21.7). One-third of the 540 NeP patients (31-36%) had their pain diagnosis reclassified from a non-NeP to a predominant/mixed NeP diagnosis after use of PainDETECT.Neuropathic pain seems to be underdiagnosed in musculoskeletal pain conditions. Use of the PainDETECT instrument may be of help to general practitioners and specialists when diagnosing NeP in chronic pain patients. However, the fact that no neurologists were included, together with the limited sample size, with large variations in the number of patients each physician included, as well as the lack of a strict consecutive recruitment process are study limitations.

OBJECTIVE: To investigate predictors of improvement in observed ability to manage activities of daily living as an outcome of rehabilitation in fibromyalgia.METHODS: Exploratory analyses used data from the Interdisciplinary Rehabilitation and Evaluation Programme for Patients with Chronic Widespread Pain (the IMPROvE study); a randomized controlled trial including 191 females with fibromyalgia randomized (1:1) to rehabilitation or a waiting list. The primary outcome was observed activities of daily living ability evaluated with the Assessment of Motor and Process Skills (AMPS) 6 months post-intervention.RESULTS: Overall, 38.7% of subjects were AMPS responders, i.e. having a clinically meaningful improvement in AMPS activities of daily living ability measures at 6 months post-intervention. In the exploratory analysis, only 4 baseline variables out of the 52 analysed showed a statistically significant interaction with treatment allocation (at the 0.05 level) indicating possible predictive value. Statistical analyses that used continuous variables dichotomized at the median suggested a predictive value of a low intake of weak and strong analgesics, and a high score of current pain and total score on the Pain Detect Questionnaire.CONCLUSION: The results of this exploratory study suggest that several subgroups of patients, specifically those with a low baseline intake of weak and strong analgesics, and more pronounced clinical signs of central sensitization, may gain most clinical benefit from specialized rehabilitation when the outcome of interest is improvement in observed activity of daily living ability.

Objective: To investigate whether the Assessment of Motor and Process Skills (AMPS), the physical function subscales of the Fibromyalgia Impact Questionnaire (FIQ PF) and the 36-item Short Form (SF-36 PF) can identify subgroups of women with fibromyalgia with clinically relevant differences in ability to perform activities of daily living. Design: Cross-sectional study. Subjects: A total of 257 women with fibromyalgia. Methods: Participants were evaluated with the AMPS (measuring activities of daily living motor and activities of daily living process ability), FIQ and SF-36. AMPS independence cut-offs were used to divide the participants into 4 subgroups. Clinically relevant differences between subgroups were investigated based on the AMPS, FIQ PF and SF-36 PF. Result: Participants in the 4 AMPS-derived subgroups demonstrated clinically relevant differences in observed activities of daily living motor and process ability. Neither the FIQ PF nor the SF-36 PF could differentiate between subgroups with clinically relevant differences in AMPS activities of daily living process ability. Conclusion: Activities of daily living process skills reflect underlying organizational and adaptive capacities of the individual and are relevant targets for interventions aiming at improving activities of daily living ability. Since self-report instruments do not capture differences in activities of daily living process ability, clinicians should include observationsbased assessment of activities of daily living ability in order to individualize interventions offered.

To compare data based on computerized and paper versions of health status questionnaires (HSQs) for sampling patient-reported outcomes (PROs) in patients with fibromyalgia (FM). In addition, to examine associations between patient characteristics (age, education, computer experience) and differences between versions. Finally, to evaluate the acceptability of computer-based questionnaires among patients with FM.Method: The study population comprised female patients diagnosed with FM. All patients completed six HSQs: the Fibromyalgia Impact Questionnaire (FIQ), the Major Depression Inventory (MDI), the 36-item Short Form Health Survey (SF-36), the painDETECT questionnaire (PDQ), the Coping Strategies Questionnaire (CSQ), and the Generalized Anxiety Disorder Self-Assessment Questionnaire (GAD-10), both on paper and using a touch screen. One HSQ was tested at a time in a repeated randomized cross-over design. The two versions were completed with a 5-min interval and between each HSQ the participants had a 5-min break. Means, mean differences with 95% confidence intervals (CIs), medians, median differences, and intraclass correlation coefficients (ICCs) were calculated for all HSQs, including relevant subscales. Associations between patient characteristics and differences between versions were explored using Spearmans correlation coefficients.Results: Twenty women, mean age 48.4 years, participated in the study. Except for one item, ICCs between touch-screen and paper versions of the HSQs examined indicated acceptable agreement (ICC = 0.71-0.99). Overall, mean and median differences revealed no differences between versions. No significant associations were observed for patient characteristics. None of the participants preferred paper questionnaires over computerized versions.Conclusions: The computerized HSQs using a touch screen gave comparable results to answers given on paper and were generally preferred by the participants.

Objective: The aim of this study was to evaluate the extent of Activities of Daily Living (ADL) ability impairment in newly arrived Danish asylum seekers. It was hypothesized that exposure to trauma and torture would negatively influence ADL performance and that measures of ADL ability would be lower in individuals exposed to torture as compared to the non-tortured. Subjects: Forty-three newly arrived asylum seekers aged 20-50 years, from Iran, Afghanistan, and Syria, were consecutively included in the study. Method: ADL ability was assessed with the observation-based test Assessment of Motor and Process Skills (AMPS). Interviews were based on questionnaires about torture exposure, WHO-5 Wellbeing Index, Major Depression Inventory and Pain Detect Questionnaire. All participants were interviewed and tested using a linguistic interpreter. Results: Thirty-three (77%) participants reported exposure to torture. The tortured did not differ significantly from the non-tortured on measures of ADL ability (two-sample t-tests: Motor, p= 0.36; Process, p= 0.82). ADL performance impairment was observed in the overall study sample. Twelve had motor and 15 process ability measures below age norms and 2 below both AMPS motor and process cut-offs for effortless and efficient ADL performance. There were statistically significant - weak to moderate - correlations between self-reported psychological distress, VAS average pain, pain distribution, and the AMPS measures. Conclusion: The study results supported significant ADL ability impairment in tortured as well as non-tortured newly arrived asylum seekers. Implementation of performance-based evaluation of ADL ability as part of the initial medical screening of this particular population should be considered.

Introduction Pain in rheumatoid arthritis (RA) is traditionally considered to be of inflammatory origin. Despite better control of inflammation, some patients still report pain as a significant concern, even when being in clinical remission. This suggests that RA may prompt central sensitisation—one aspect of chronic pain. In contrast, other patients report good treatment response, although imaging shows signs of inflammation, which could indicate a possible enhancement of descending pain inhibitory mechanisms. When assessing disease activity in patients with central sensitisation, the commonly used disease activity scores (eg, DAS28-CRP (C reactive protein)) will yield constant high total scores due to high tender joint count and global health assessments, whereas MRI provides an isolated estimate of inflammation. The objective of this study is, in patients with RA initiating anti-inflammatory treatment, to explore the prognostic value of a screening questionnaire for central sensitisation, hand inflammation assessed by conventional MRI, and the interaction between them regarding treatment outcome evaluated by clinical status (DAS28-CRP). For the purpose of further exploratory analyses, dynamic contrast-enhanced MRI (DCE-MRI) is performed. Method and analysis The painDETECT Questionnaire (PDQ), originally developed to screen for a neuropathic pain component, is applied to indicate the presence of central sensitisation. Adults diagnosed with RA are included when either (A) initiating disease-modifying antirheumatic drug treatment, or (B) initiating or switching to biological therapy. We anticipate that 100 patients will be enrolled, tested and reassessed after 4 months of treatment. Data collection includes Clinical data, conventional MRI, DCE-MRI, blood samples and patient-reported outcomes. Ethics and dissemination This study aims at supporting rheumatologists to define strategies to reach optimal treatment outcomes in patients with RA based on chronic pain prognostics. The study has been approved by The Capital region of Denmark9s Ethics Committee; identification number H-3-2013-049. The results will be published in international peer-reviewed journals.

Falanga is an ancient form of punishment or torture but is still commonly reported by our refugees. The late result of caning the heel and ball of the foot is a chronic painful condition with few clinical signs. The aim of the present study was to assess, by MRI, possible morphologic characteristics of the heel and ball of the foot, related to falanga and pain in correlation to clinical findings. Magnetic resonance imaging of the foot was obtained in 12 victims exposed to falanga torture and 9 healthy volunteers. Sagittal T1-weighted spin-echo images (TR 616–840 ms, TE 20 ms), T2-weighted spin-echo images (TR 1900 ms, TE 90 ms), and short tau inversion recovery (STIR) images (TR 1200 ms, TE 15 ms, TI 100 ms) were performed. The central portion of the plantar aponeurosis was generally significantly thicker in victims exposed to falanga torture as compared with that of controls (P < 0.05). In all except one of the victims, MRI demonstrated two layers of the thickened plantar aponeurosis: a deeper portion with normal homogeneous low signal intensity (SI) appearance, and a superficial layer with characteristic areas of mixed SI on both T1- and T2-weighted images. There were no signs of chronic muscular compartment syndromes, and the thickness of the plantar pad did not differ between the two groups. Magnetic resonance imaging may demonstrate morphologic characteristics of the plantar aponeurosis which may confirm falanga torture. Further imaging with more specific sequences is warranted to demonstrate the supposed injuries in the compartmental fat tissue chambers and the vascularity of the ball pad of the foot.

OBJECTIVE.: To assess pain sensitivity and spreading hyperalgesia in lateral epicondylalgia (LE). SUBJECTS.: Twenty-two women with LE, and 38 controls were included. OUTCOME MEASURES.: Computerized cuff pressure algometry was used for assessment of pressure-pain threshold and tolerance. The stimulus was applied using a single (stimulation-area: 241 cm(2) ) or double-chambered (stimulation-area: 482 cm(2) ) tourniquet on the arm and leg. Spatial summation was expressed as the ratio between pressure-pain thresholds to single and double cuff-chamber stimulation. During 10-minute constant pressure stimulation at intensity relative to the individual pain threshold, the pain intensity was continuously recorded using an electronic visual analogue scale (VAS), and from this the degree of temporal summation was estimated. For LE, a Doppler ultrasound examination of the elbow was made to identify inflammation. RESULTS.: In LE compared with controls the pressure-pain threshold and tolerance were on average reduced by respectively 31% (nonsignificant) and 18% (nonsignificant) on the lower arm and by 32% (P < 0.05) and 22% (P < 0.05) on the lower leg (spreading sensitization). Within the LE group, pressure-pain thresholds were on average reduced by 20% (P < 0.05) and pain tolerance by 10% (nonsignificant) on the painful compared with the asymptomatic side. Spatial summation (P < 0.01) and temporal summation (P < 0.05) was facilitated in LE compared with controls. In LE patients without signs of peripheral inflammation assessed by Doppler ultrasound, temporal summation was significantly stronger than in patients with ongoing inflammation (P < 0.01). CONCLUSION.: Patients with LE may be subgrouped based on pain hypersensitivity and Doppler ultrasound into clinically meaningful subgroups with varying duration of symptoms and different degrees of central sensitization. These groups may require different pain management strategies.

Emerging evidence suggests that pain might be more effectively classified and treated according to the mechanisms underlying the onset and/or the maintenance of pain. Multiple mechanisms that can produce pain have been identified, including tissue injury and inflammation (inflammatory pain), damage to the nervous system (neuropathic pain), and abnormal responsiveness or function of the central nervous system (central sensitization, dysfunction of descending pain modulating systems). Central pain mechanisms may play an important role in rheumatic diseases, traditionally considered peripheral inflammatory entities. Inflammation sensitizes polymodal nociceptors. This peripheral sensitization induces hyperexcitability of nociceptive neurons in the central nervous system (central sensitization) and the two together generate the features of pathological pain, allodynia and hyperalgesia, confined to the inflamed tissues. Increased responsiveness of peripheral and central neurons (pain hypersensitivity) in the presence of tissue injury and inflammation is a normal response (neuroplasticity). As a rule, these sensitization phenomena extinguish themselves as the tissue heals and inflammation subsides. However, persistent pain is common in patients with inflammatory joint disorders and the key question is whether these neuroplastic changes persists in subsets of patients and leads to chronic pain states in which pain is no longer coupled to the presence of ongoing peripheral inflammation. If central pain mechanisms do play a significant role in pain processing and persistence of pain in subgroups of patients, strategies for managing pain in addition to inflammatory disease suppression may be required. Furthermore, in these patients, persistent pain hypersensitivity may lead to continuous high reports of tender joints and poor global health and pain leaving the physician with the clinical dilemma that patient reported outcomes and composite disease activity scores do not correspond to the objective level of inflammatory activity. Simple methods assisting identification of underlying pain mechanisms in the clinical care of rheumatologic patients are therefore needed. The painDETECT Questionnaire (PDQ) is a patient administered screening questionnaire originally developed to determine the likelihood of a predominant neuropathic pain component being present. The questionnaire comprises 7 weighted somatosensory symptom and sign items and 2 items relating to the spatial (radiating) and temporal characteristics of the individual pain pattern. Although developed as a screening questionnaire for neuropathic pain, the PDQ has increasingly been used to assess neuropathic pain features as a proxy of central pain mechanisms in, for example, patients with osteoarthritis and fibromyalgia. Recently, the PDQ has also been introduced in studies assessing pain mechanisms in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA). The clinical utility of the PDQ in patients with arthritis will be covered based on patient cases, registry data and clinical studies. The prevalence and description of PDQ-derived pain phenotypes and the prognostic value thereof will be discussed. Disclosure of Interest None declared

Background Functional ability, which includes the ability to perform activities of daily living (ADL), is considered a core outcome domain in rheumatology. Recommendations for assessing ADL ability include the use of generic and diseases-specific questionnaires based on self-report and one of the most frequently used instruments is the Health Assessment Questionnaire Disability Index (HAQ-DI). Self-report reflects the person9s perception of extent of disability, which may be influenced by pain and other psychosocial factors. A poor agreement between self-reported and observed ADL ability has previously been demonstrated in rheumatic populations based on other self-report instruments. Objectives to evaluate relationships between HAQ-DI scores and measures of observed ADL ability in patients with inflammatory and non-inflammatory rheumatic diseases and the association between pain and fatigue and these disability measures. Methods patients with rheumatoid arthritis (RA), knee osteoarthritis (OA) and fibromyalgia (FM) were assessed with the HAQ-DI. The Assessment of Motor and Process Skills (AMPS) was used to obtain measures of observed ADL ability. Two domains of observed ADL ability were evaluated: ADL motor skills (moving self and objects) and ADL process skills (organizing and adapting actions). Pain and fatigue were assessed by 100mm visual analogue scales (VAS). The project was approved by the local ethical committee (H-B-2007–084). Results 143 women (50 with RA, 27 with knee OA, 66 with FM), mean age 51.2 (11.8) participated. Baseline characteristics and correlations are presented in table 1. Patients with FM had the highest pain, fatigue, and HAQ disability scores and the poorest performance on the AMPS. The relationships between self-reported and observed ADL motor ability were weak to moderate across all diagnostic groups; strongest in patients with knee OA. Relationships with the AMPS ADL process ability measure were weak to insignificant. Level of pain, and not fatigue, showed the strongest relationship with self-reported functional ability across all diagnostic groups. A weak to moderate relationship between pain and AMPS ADL motor ability measures were also present in patients with RA and OA, but insignificant in patients with FM (r= -0.16, p=0.195). Conclusions the relation between self-reported and observed functional ability is low across a spectrum of musculoskeletal diagnoses, even when using instruments recommended for these populations including the HAQ-DI. This has major implications on how to interpret and measure functional ability in the future as both methods should probably accompany each other. Interestingly pain was not associated with observed motor ADL ability in FM as opposed to RA and OA. Disclosure of Interest None declared

Background Pain in rheumatoid arthritis (RA) is typically regarded as related to on-going synovial inflammation in peripheral joints. However, in a subgroup of patients evidence indicates that pain can become an entity of its own caused by central sensitization (CS), elicited by but in time not directly related to ongoing inflammation. The painDETECT questionnaire (PDQ) was developed to differentiate neuropathic pain from unclear and non-neuropathic pain. In several studies it has been used to indicate CS owing to similarities in somatosensory profiles. Magnetic resonance imaging (MRI) can be used as an objective inflammation marker, quantified by the RA MRI Score (RAMRIS). Objectives To evaluate the prognostic value of a PDQ score >18 on DAS28 response in RA patients taking a possible interaction with inflammation defined by RAMRIS synovitis scores into account. Methods RA patients were included when they were to: 1) initiate a disease modifying antirheumatic drug (DMARD) or 2) initiate or switch a biological agent. At baseline and after 4 month of follow up patients went through an examination program incl. standard demographics, clinical examination, hand MRI, patient reported outcomes (incl. PDQ), and blood samples. Least-Squares Mean change (95% CI) was calculated using ANCOVA adjusting for the value at baseline. Multivariable regressions with DAS28 or RAMRIS synovitis change as outcome were performed to determine the prognostic variables. The model included PDQ-category, RAMRIS synovitis score and their interaction. Possible confounders were: gender, disease duration, baseline DAS28, and initiation group. PDQ score was interpreted as: >18 indication of CS, 13–18 unclear pain mechanism, Results 102 patients were included, 75 had an MRI scan performed. Mean changes stratified by PDQ-group are presented in the table showing the greatest changes in the CS-group (>18). Only baseline DAS28 was a significant predictor of DAS28 change (P 18) at baseline all had changed classification-group at follow-up (8 to nociceptive pain and 4 to unclear). Conclusions In this pragmatically sampled population of RA patients, pain classification by PDQ at treatment initiation had no prognostic value with regard to change in DAS28 or RAMRIS synovitis. In contrast, all patients classified with indication of CS by PDQ at baseline changed classification group and were even to gain most from treatment start in net changes. This might indicate that in RA, CS reflects normal neuroplasticity that is reversible with reduction of inflammation. References Koroschetz J, et al. Fibromyalgia and neuropathic pain-differences and similarities. A comparison of 3057 patients with diabetic painful neuropathy and fibromyalgia. BMC Neurol 2011;11:55 Disclosure of Interest None declared

INTRODUCTION: Persistent pain is a major concern for patients with psoriatic arthritis (PsA). Pain may be due to inflammatory activity or augmented central pain processing. Unawareness of the origin and mechanisms of pain can lead to misinterpretation of disease activity (by composite scores) and erroneous treatments. Ultrasonography (US) is a highly sensitive method to detect tissue inflammation. Evaluating pain mechanisms in relation to US measures may prove valuable in predicting response to treatment in PsA.AIMS: To study the association and prognostic value of pain mechanisms, ultrasonic activity and clinical outcomes in patients with PsA who intensify antirheumatic treatment.METHODS AND ANALYSES: 100 participants >18 years of age with PsA who initiate or switch antirheumatic treatment (biologicals and/or conventional synthetic disease-modifying antirheumatic drugs (DMARDs)) will be prospectively recruited from outpatient clinics in Copenhagen. All data (demographics, clinical, imaging, blood samples and patient-reported outcomes) will be collected at baseline and after 4 months. Pain is assessed by the PainDETECT Questionnaire, Visual Analogue Scale for pain, Swollen to Tender Joint Count Ratio, Widespread Pain Index and tender point examination. The association between pain variables and clinical/US characteristics will be described by correlation analyses. The predictive value of pain measures and baseline US scores on treatment response will be analysed with regression models. Outcomes are composite and clinical, as well as patient reported.ETHICS AND DISSEMINATION: The study is approved by the ethics committee of the Capital Region of Denmark (H-15009080) and has been designed in cooperation with patient research partners. The study is registered at clinicaltrials.gov (number NCT02572700). Results will be disseminated through publication in international peer-reviewed journals.TRIAL REGISTRATION NUMBER: NCT02572700, Pre-results.

ObjectiveTo investigate relationships between perceived and objectively measured muscle fatigue during exhausting muscle contractions in women with fibromyalgia (FM) compared with healthy controls (HC).MethodsWomen with FM and HC completed an isometric muscle exhaustion task at 90° shoulder abduction. Surface electromyographic (EMG) activity in the deltoid muscle was recorded together with self-reported level of muscle fatigue.Results25 participants with FM and 23 HC were included. Average time to exhaustion was 254 s shorter in participants with FM than in HC. Participants with FM did not exhibit the same level of objective signs of muscle fatigue, seen as fewer changes in the EMG activity, as the HC during the exhaustion task. The task did not provoke pain in the HC, while participants with FM reported a doubling of pain.ConclusionsWomen with FM had shorter exhaustion times and showed fewer objective signs of muscle fatigue during an exhausting isometric shoulder abduction compared with younger HC. This indicates that perceived muscle fatigue may be of central origin and supports the notion of central nervous dysfunction as basic pathological changes in FM.

Knowledge about functional ability, including activities of daily living (ADL), in patients with chronic widespread pain (CWP) and fibromyalgia (FMS) is largely based on self-report. The purpose of this study was to assess functional ability by using standardised, observation-based assessment of ADL performance and to examine the relationship between self-reported and observation-based measures of disability. A total of 257 women with CWP, 199 (77%) fulfilling the American College of Rheumatology tender point criteria for FMS, were evaluated with the Assessment of Motor and Process Skills (AMPS), an observation-based assessment providing linear measures of ADL motor and ADL process skill ability (unit: logits). A cutoff for effortless and independent ADL task performance is set at 2.0 for the motor scale and 1.0 for the process scale. A total of 248 (96.5%) had ability measures below the 2.00 ADL motor cutoff and 107 (41.6%) below the 1.00 ADL process cutoff, indicating increased effort and/or inefficiency during task performance as well as a potential need of assistance for community living. Mean ADL motor ability measure was 1.07 and was significantly lower in patients diagnosed with FMS than plain CWP (1.02 vs 1.27 logits, P = .001). Mean ADL process ability measure was 1.09 logits and was without difference between FMS and plain CWP (1.07 vs 1.16 logits, P = .064). Only weak to moderate correlations between self-reported functional ability and observation-based AMPS ability measures were observed. The results of the study support the notion of considerable performance difficulties in women with CWP. The everyday life problems are substantial and place the individual at risk of need of support for community living.

Fibromyalgia is characterised by chronic widespread pain and mechanical hyperalgesia. It is associated with a higher pain intensity, fewer pain-free intervals and more pronounced pain-related interference in function than other musculoskeletal pain conditions. Increasing evidence supports an underlying augmented central pain processing which includes sensitization of pain-transmitting neurons and dysfunction of pain inhibitory pathways. If this permanent change in the function of the nociceptive system is shown to equal fibromyalgia, the condition may be considered a neuropathic pain condition.

It is important to recognize the diagnosis of fibromyalgia (FM) to adequately advise patients with this chronic pain disease. FM coexists with other rheumatic diseases and may therefore serve as a confounder in connection with estimation of disease activity. The aetiology and pathogenesis of FM remain unknown, although central sensitisation seems to play a major role. Following exclusion of a number of differential diagnoses, the remaining patients have several treatment options including centrally-acting medication.

Widespread pain and pain hypersensitivity are the hallmark of fibromyalgia, a complex pain condition linked to central sensitization. In this study the painDETECT questionnaire (PDQ), validated to identify neuropathic pain and based on pain quality items, was applied in a cross-sectional sample of patients with chronic widespread pain (CWP). The aims of the study were to assess the patient-reported sensory neuropathic symptoms by PDQ and to correlate these with tender point (TP) count and pressure-pain thresholds. Eighty-one patients (75 F, 6 M) with CWP (ACR-criteria) filled in the PDQ. Manual TP examination was conducted according to ACR guidelines. Computerized cuff pressure algometry was used for the assessment of pressure-pain detection thresholds (PDT, unit: kPa) and pressure-pain tolerance thresholds (PTT, unit: kPa). Mean TP count was 14.32 (range: 2–18), mean PDQ score 22.75 (range: 5–37). Mean PDT was 8.8 kPa (range: 2–36) and mean PTT 30.9 kPa (range: 4–85). Deep-tissue hyperalgesia was the predominant somatosensory symptom reported in 83%, but other neuropathic symptoms were also frequent, e.g. burning 51% and prickling 47%. Statistically significant correlations were found between PDQ score and TP count: r = 0.35 (p < 0.01), and PDQ score and PDT: r = 0.45 (p < 0.01), and PTT: r = 0.43 (p < 0.01). The study indicates that pain in CWP has neuropathic features, and that the presence and number of tender points are associated with neuropathic pain symptoms. A high mean PDQ score was found to correlate with TP count and pressure-pain thresholds. The PDQ may become a useful tool assisting in the identification of central sensitization in patients with CWP and in the future diagnostic assessment fibromyalgia.

To investigate whether signs of chronic compartment syndrome could be found in plantar muscles of falanga torture victims with painful feet and impaired gait. The hypothesis was that the muscular vascular response to two minutes ischemia would be decreased in torture victims compared to controls. On color Doppler this would be seen as less color after ischemia and on spectral Doppler as elevated resistive index (RI).Ten male torture victims from the Middle East and nine age, sex and ethnically matched controls underwent Doppler examination of the abductor hallucis and flexor digitorum brevis muscles before and after two minutes ischemia induced with a pressure cuff over the malleoli. The color Doppler findings were quantified with the color fraction (CF) before and after ischemia. On spectral Doppler the resistive index was measured once before and three consecutive times after ischemia.Both torture victims and controls responded to ischemia with an increased CF. There was no difference between torture victims and controls. With spectral Doppler all subjects had an RI of 1.0 before ischemia. After ischemia, in nearly all subjects and all muscles the first RI was lowest, the second was higher and the third was highest indicating that the response to ischemia was disappearing as measurements were made. There was a trend that the first RI was higher in torture victims than in controls.The study was not able to confirm the presence of chronic compartment syndrome. However, the trend in RI still supports the hypothesis. The negative findings may be due to inadequate design where the CF and RI were measured in one setting, perhaps resulting in both methods being applied imperfectly. The response to ischemia seems short-lived and we suggest that the Doppler methods may be re-evaluated with separate ischemic phases for CF and RI.

Medico-legal documentation of alleged exposure to falanga torture warrants a high diagnostic accuracy of the applied clinical tests. The objective of this study was to establish data on the validity of palpatory examination of the footpads and the plantar fascia and to assess the distribution of observations among selected cases and non-cases in a small study sample. Calculated estimates of sensitivity and specificity of the individual diagnostic tests are reported and, in general, did not meet the authority-based criteria of an 80% cut-off point. The observed total number of true tests in this study was 65 %. It is concluded that future studies of the reliability of clinical examination and assessment of the variability of observations among unselected cases and non-cases should be conducted in a larger cross-sectional study population.

The long-term consequences of falanga are probably the best described consequences of exposure to specific forms of physical torture. Theories about casual lesions in the peripheral tissues of the feet have been put forward based on clinical observations along with international guidelines for the clinical assessment, but still knowledge is needed in several areas. A review of the literature on falanga is presented, mainly focusing on the clinical aspects and possible lesions caused by this specific form of torture that may influence the overall management of the condition. Finally, the article closes with a call for future research, which is needed in order to advance a knowledge-based development of the applied clinical practice.

Five British men were detained and allegedly tortured in Saudi Arabia in 2000 and 2001. Two were sentenced to death and three were sentenced to 12 to 18 years of imprisonment. They received clemency in 2003 and were deported to England. After their homecoming, the men have unsuccessfully attempted to sue Saudi Arabian officials who had been responsible for their false accusations and human rights abuses. Saudi Arabia denies any form of torture and ill treatment of the five men, who maintain their allegations against the authorities responsible in Saudi Arabia. This article provides medical documentation of torture of the five British men by comparing: 1. Alleged torture methods, 2. Histories of immediate effects of torture, 3. Objective medical observations using clinical examinations as well as ultrasound scans of the victims' feet. The article concludes that there is a high degree of consistency between the claims of torture and observations, despite Saudi Arabian denial.

Falanga torture involves repetitive blunt trauma to the soles of the feet and typically leaves few detectable changes. Reduced elasticity in the heel pads has been reported as characteristic sequelae and palpatory testing of heel pad elasticity is therefore part of medicolegal assessment of alleged torture victims. The goal was to test the accuracy of two experienced investigators in determining whether a heel pad model was soft, medium or hard. The skin-to-bone distance in the models varied within the human range. Method Two blinded investigators independently palpated nine different heel pad models with three different elasticities combined with three different skin-to-bone distances in five consecutive trials and categorized the models as soft, medium or hard. Results Two experienced investigators were able to identify three known elasticities correctly in approximately two thirds of the cases. The skin-to-bone distance affected the accuracy. Conclusion The use of clinical examination in documenting alleged exposure to torture warrants a high diagnostic accuracy of the applied tests. The study implies that palpatory testing of the human heel pad may not meet this demand. It is therefore recommended that a device able to perform an accurate measurement of the viscous-elastic properties of the heel pad be developed.