INTRODUCTION:Chronic pain is a significant and debilitating symptom observed in individuals with post-COVID condition (PCC), yet the underlying mechanisms remain poorly understood. This study aimed to investigate whether changes in psychophysical indicators of myofascial pain perception and modulation are present in individuals with PCC compared to symptom-free healthy controls (HC), and whether these changes correlate with the severity of clinical symptoms. METHODS:The study involved 84 individuals with PCC and 50 HC, assessing pain detection and tolerance thresholds (PDT and PTT), spatial and temporal summation of pain (SSP and TSP), and conditioned pain modulation (CPM) using phasic cuff pressure on the legs. RESULTS:Results indicated that individuals with PCC exhibited lower PDT and PPT (PDT: d = -0.557, p = 0.0022; PTT: d = -0.575, p = 0.0016), increased TSP (d = 0.424, p = 0.02) and decreased SSPPTT (d = -0.532, p = 0.0038) compared to HC CPM effects (CPMPDT: p = 0.058; CPMPTT: p = 0.43) did not differ significantly between groups but post hoc analysis revealed a significantly higher proportion of inhibitory responders among HC. Subgroup analyses highlighted that these effects were particularly pronounced in participants that reported chronic pain among their PCC symptoms, as well as those with more severe PCC symptomatology. CONCLUSION:The findings suggest that individuals with PCC demonstrate altered myofascial pain perception, indicative of central sensitization. These results underscore the need for further research into targeted therapeutic strategies for managing chronic pain in PCC. SIGNIFICANCE STATEMENT:Individuals with post-COVID condition (PCC) often experience persistent pain. Using quantitative sensory testing of deep tissue pain, we found that individuals with PCC had lower pain detection and tolerance thresholds, stronger spatial and temporal summation, and a higher proportion of facilitatory conditioned pain modulation compared to healthy controls. This pattern is consistent with nociplastic pain, suggesting altered central pain processing in PCC. Understanding these mechanisms is essential for developing targeted treatments of chronic pain in this growing patient population.

Introduction: Fibromyalgia syndrome (FMS) and major depressive disorder (MDD) frequently co-occur together, but the mechanisms linking these conditions remain poorly understood. This study aimed to delineate symptom clusters within the FMS-MDD network, identify bridging symptoms connecting these clusters, and evaluate the integrative role of Pain Intensity. Methods: Cross-sectional data from 3,044 patients with FMS (94% female; mean age = 52.4, SD = 9.28) were analyzed using a mixed graphical model. From an initial pool of 238 items, 30 symptom nodes were selected through a systematic reduction process. Results: The analysis revealed seven distinct symptom clusters: Pain Intensity and Functional Impact, Autonomic and Somatic Complaints, Trauma and Anxiety-driven Symptomatology, Sexual and Health Concerns, Anhedonia and Social Disconnection, Cognitive-Affective and Psychomotor Dysfunctions, and Sleep, Energy Levels, and Social Functioning. Six symptoms were identified as key bridges between clusters, with depressed mood (z = 2.43), fatigue (z = 2.06), and anxiety and nervousness (z = 2.09) showing the highest bridge centrality. Surprisingly, pain intensity exhibited minimal connectivity, ranking 18th in bridge strength (z = - 0.59), and primarily linked to sleeping problems and fatigue. Conclusion: Our findings suggest that emotional and fatigue-related symptoms play a more central role in linking FMS and depression than Pain Intensity alone. Bridge symptoms such as fatigue and depressed mood may represent clinically meaningful targets for symptom-focused interventions. As this study is cross-sectional, causal inferences cannot be drawn. Longitudinal studies are needed to examine temporal dynamics and test whether targeting bridge symptoms improves clinical outcomes.

ABSTRACT:The global SARS-CoV-2 pandemic has led to a significant portion of COVID-19 survivors experiencing prolonged symptoms, including persistent pain. Although previous research has identified sociodemographic and clinical predictors for post-COVID pain, the impact of psychological factors remains elusive. This study investigated the prevalence, predictors, and characteristics of persistent musculoskeletal pain and headache 1.5 years after SARS-CoV-2 infection, focusing on the impact of psychological distress during acute infection. From an initial pool of 548 cases reported as SARS-CoV-2 positive to local health authorities, 422 individuals (58% female, median age: 52 years) were prospectively examined. Screening during acute infection included assessment of somatic symptoms and psychological distress. At 18 months postinfection, a follow-up evaluated self-reported long-term symptoms. Minimum possible prevalence rates (assuming all non-responders had fully recovered) of patient-attributed post-COVID de novo pain were 5.0% for musculoskeletal pain and 5.5% for headache. De novo musculoskeletal pain commonly affected the lower extremities, shoulders, and neck, whereas de novo headache primarily involved frontoparietal and fronto-orbital regions, with predominantly bilateral distribution. Both acute SARS-CoV-2 symptom severity and psychological factors were associated with spatial distribution of musculoskeletal pain and impact of musculoskeletal pain and headache. Firth regression with exploratory backward elimination identified depressiveness, posttraumatic stress, and average level of psychological distress perceived during the acute infection as potentially relevant predictors for patient-attributed post-COVID pain. This study provides preliminary evidence that psychological distress during acute infection may contribute to persistent patient-attributed post-COVID pain and headache, either as a predictor for its occurrence or by shaping pain perception.

This study investigates the associations between early childhood adversities, stress perception, and fibromyalgia syndrome (FMS). Although the interconnection between dysregulated stress systems and FMS is well documented, the interconnection between early adversities and FMS remains less understood. This study explores the relationship of early-life stress and FMS by examining its mediation through perceived stress, and acute and chronic endocrine stress indicators. Stress was assessed using the perceived stress scale, as well as using salivary and hair cortisol as endocrine indicators of acute and chronic stress, respectively. The sample consisted of 99 individuals with FMS and 50 pain-free controls. A structural equation model was used to assess the mediating effects of stress indicators between early adversities and the severity of FMS. Compared with controls, individuals with FMS had notably higher early adversity scores (d = 0.63) and greater occurrence of exposure to adversity (78.8% vs 66%). Structural equation modeling indicated that the influence of early adversities on FMS symptoms is mediated by perceived stress levels, with no direct effect observed. Our findings indicate that early-life adversity is a significant determinant of the development of FMS, with the relationship between these factors mediated by perceived stress rather than by endocrine stress indicators. These results underscore the critical role of stress perception in the development and management of FMS, suggesting that perceived stress may serve as a valuable therapeutic target. Incorporating trauma-informed and stress-targeted care into treatment strategies could significantly improve outcomes for individuals with FMS, emphasizing the importance of addressing psychological factors alongside physical symptoms.

Fibromyalgia syndrome (FMS) is a chronic disorder characterized by widespread musculoskeletal pain, fatigue and tenderness and closely associated with high levels of stress. FMS is therefore often considered a stress-related disease. A comparative study was conducted with 99 individuals diagnosed with FMS and a control group of 50 pain-free individuals. Stress indicators were classified into three categories: perceived stress assessed using the Perceived Stress Scale, and daily average salivary cortisol and hair cortisol concentrations as indicators of acute and chronic stress levels related to the hypothalamic-pituitary-adrenal axis. Analysis of variance and covariance were used to identify group differences and the influence of covariates age, sex, and body mass index. Correlational analyses further elucidated the relationship between stress indicators and clinical symptoms. Participants with FMS reported significantly higher perceived stress levels than controls (p < .001, ηp2 = 0.3), which were positively correlated with symptom burden (r = .41, p < .001). In contrast, there were no significant differences in the endocrinological stress indicators salivary and hair cortisol between the groups (p > .05), nor were these indicators associated with clinical symptoms. The study highlights the central role of perceived stress in FMS, whereas endocrinological indicators did not differentiate FMS from controls. This finding calls for a nuanced approach to clinical assessment and therapeutic interventions tailored to patients with FMS, emphasizing the management of perceived stressors.

BackgroundEye Movement Desensitization and Reprocessing (EMDR) is an evidence-based treatment, primarily established for post-traumatic stress disorder (PTSD). While it is increasingly being applied to chronic pain, its efficacy in this area is not yet supported by the same level of evidence as that which exists for PTSD. Studies in this area often show heterogeneous results with small case numbers, and the potential side effects of EMDR in the treatment of chronic pain are not well understood. Systematic documentation of treatment effects, potential predictors of treatment response and non-response, and side effects is crucial for progress in this field.AimThe primary aim is to establish a research framework to systematically investigate the delivery of EMDR therapies by outpatient clinicians in the field of pain. This study aims to provide a comprehensive analysis of treatment outcomes, side effects and determinants of treatment effectiveness, whether positive response or non-response.MethodsThis framework will oversee the documentation and evaluation of EMDR interventions delivered in outpatient settings using an Embedded Continuous Cumulative Evaluation Design (ECCED). It will focus on detailed characterisation of positive and negative therapeutic effects. It will also identify and analyse prognostic factors that influence individual variability in response to treatment. Treatment materials, standardised assessments and an intervision platform for regular exchange will be provided.DiscussionThe establishment of the EMDR Pain Network Germany and an interdisciplinary scientific-clinical platform is essential to promote clinical exchange and understanding of the effects of EMDR in pain therapy. This platform offers standardised treatment protocols, an online data collection system with anonymised data, comprehensive baseline assessments and an intervision platform for regular exchange. The knowledge gained is intended to personalise future therapies and serve as a basis for large randomised clinical trials.

Background The treatment of persistent fatigue after COVID-19 infection is complex. On the one hand, it involves maintaining a sufficient level of physical and mental activity to counteract possible degenerative processes of the body and nervous system. On the other hand, physical and mental activities can also lead to worsening of symptoms. Therefore, the challenge in treating Post-COVID fatigue is to stimulate the body and central nervous system in a way that stimulates growth and improvement, but does not overtax individual physical and mental limits. Special training programs try to take these characteristics into account, but often reach their limits. A promising approach is offered by new fitness technologies based on immersive virtual realities that stimulate both body and brain while minimizing physical and psychological stress. The aim of this study is to investigate the efficacy of supervised immersive Virtual Reality (VR)-based activity training compared to conventional activity training for patients with Post-COVID-associated fatigue. Methods In a single centre, individually randomised, prospective, double-blind two-arm exploratory superiority trial with parallel group design, N = 100 patients with persistent fatigue after COVID-19 infection will be recruited. The intervention includes a supervised immersive neuromuscular training (12 sessions of 30 min over 6 weeks) based on a novel VR-exercise device. We will systematically compare the effects of this intervention on Post-COVID-associated fatigue with a supervised conventional activation program of comparable scope without an immersive environment. The primary outcome is the difference between groups in absolute change in the mean fatigue symptom severity measured on the Fatigue Severity Scale (FSS) from baseline to posttreatment assessment. Posttreatment assessment in both groups will be conducted by blinded outcome assessors. At three and six months afterwards, patients are sent self-report questionnaires for follow up. The main analysis will be based on the intention-to-treat principle. Discussion To the best of our knowledge, this is the first exploratory study on a supervised immersive neuromuscular training for the treatment of persistent fatigue after COVID-19 infection. Trial registration German register for clinical studies (ID: DRKS00032059) Prospectively registered on June 16th 2023. URL of trial registration:

The majority of knowledge about fibromyalgia syndrome (FMS) derives from studies of female patients. Little is known about the clinical characteristics and treatment outcomes of male patients with FMS. In this retrospective cohort study with a prospective posttreatment follow-up, we investigated whether male patients with FMS differ from female patients in terms of 1) symptom burden, 2) psychological characteristics, and 3) clinical treatment response. We identified 263 male (4%) out of 5,541 patients with FMS completing a 3-week multimodal pain-treatment program. Male patients (51.3 +/- 9.1 years) were age- and time-matched (1:4) with female patients (N = 1,052, 51.3 +/- 9.0 years). Data on clinical characteristics, psychological comorbidities, and treatment responses were obtained from medical records and validated questionnaires. Levels of perceived pain, psychological comorbidity, and functional capacity were similar between genders, although male patients with FMS showed a higher prevalence of alcohol abuse. Compared to female patients, male patients experienced themselves less often as overly accommodating (Cohen's d = -.42) but more often as self-sacrificing (d = .26) or intrusive (d = .23). Regarding pain coping, male patients were less likely to utilize mental distraction, rest- and relaxation techniques, or counteractive activities (d = .18-.27). Male patients showed a slightly worse overall response rate than women (69% vs 77%), although differences between individual outcome measures were small (d < .2). Although male and female patients in our cohort were similar in clinical presentation and treatment response, the gender-specific differences in interpersonal problems and pain coping suggest consideration of these aspects in the treatment of male patients with FMS.Perspective: Knowledge about fibromyalgia mostly derives from studies of female patients. Identifying and understanding gender-specific differences in fibromyalgia is an important roadmap in the treatment of this syndrome by focusing on specific gender aspects such as differences in interpersonal problems and pain coping mechanisms. (c) 2023 (c) Published by Elsevier Inc. on behalf of United States Association for the Study of Pain, Inc All rights reserved.

ObjectiveSomatic symptom disorder (SSD) is one of the most common reasons for consultations in primary care, in addition to simple acute infections. Questionnaire-based screening instruments to identify patients at high risk of SSD are thus of great clinical relevance. Although screening instruments are frequently used, it is currently unclear to what extent they are influenced by the concurrent presence of simple acute infections. Therefore, this study aimed to investigate how symptoms of simple acute infections affect the two established questionnaires as screening instruments for somatic symptom disorder in the primary care setting.MethodsIn our cross-sectional, multicenter design, a total of 1,000 patients in primary care practices were screened using the two most established SSD screening questionnaires, the 8-item Somatic Symptom Scale (SSS-8) and the 12-item Somatic Symptom Disorder—B Criteria Scale (SSD-12), followed by clinical assessment by the primary care physician.ResultsA total of 140 patients with a simple acute infection (acute infection group, AIG) and 219 patients with chronic somatic symptoms (somatic symptom group, SSG) were included. The patients in the SSG showed higher total SSS-8 and SSD-12 scores than the patients in the AIG; however, the SSS-8 was more susceptible to changes triggered by symptoms of a simple acute infection than the SSD-12.ConclusionThese results suggest that the SSD-12 is less susceptible to symptoms of a simple acute infection. Its total score and corresponding cutoff value provide a more specific and thus less susceptible screening tool for identifying SSD in primary care.

BackgroundChronic musculoskeletal pain (CMSP) affects between 13% and 47% of the population, with a global growth rate of 20.3% within the last 15 years, suggesting that there is a high need for effective treatments. Pain diaries have long been a common tool in nonpharmacological pain treatment for monitoring and providing feedback on patients’ symptoms in daily life. More recently, positive refocusing techniques have come to be used, promoting pain-free episodes and positive outcomes rather than focusing on managing the pain. ObjectiveThis study aims to evaluate the feasibility (ie, acceptability, intervention adherence, and fidelity) and initial signals of efficacy of the PerPAIN app, an ecological momentary intervention for patients with CMSP. The app comprises digitalized monitoring using the experience sampling method (ESM) and feedback. In addition, the patients receive 3 microinterventions targeted at refocusing of attention on positive events. MethodsIn a microrandomized trial, we will recruit 35 patients with CMSP who will be offered the app for 12 weeks. Participants will be prompted to fill out 4 ESM monitoring questionnaires a day assessing information on their current context and the proximal outcome variables: absence of pain, positive mood, and subjective activity. Participants will be randomized daily and weekly to receive no feedback, verbal feedback, or visual feedback on proximal outcomes assessed by the ESM. In addition, the app will encourage participants to complete 3 microinterventions based on positive psychology and cognitive behavioral therapy techniques. These microinterventions are prompts to report joyful moments and everyday successes or to plan pleasant activities. After familiarizing themselves with each microintervention individually, participants will be randomized daily to receive 1 of the 3 exercises or none. We will assess whether the 2 feedback types and the 3 microinterventions increase proximal outcomes at the following time point. The microrandomized trial is part of the PerPAIN randomized controlled trial (German Clinical Trials Register DRKS00022792) investigating a personalized treatment approach to enhance treatment outcomes in CMSP. ResultsApproval was granted by the Ethics Committee II of the University of Heidelberg on August 4, 2020. Recruitment for the microrandomized trial began in May 2021 and is ongoing at the time of submission. By October 10, 2022, a total of 24 participants had been enrolled in the microrandomized trial. ConclusionsThis trial will provide evidence on the feasibility of the PerPAIN app and the initial signals of efficacy of the different intervention components. In the next step, the intervention would need to be further refined and investigated in a definitive trial. This ecological momentary intervention presents a potential method for offering low-level accessible treatment to a wide range of people, which could have substantial implications for public health by reducing disease burden of chronic pain in the population. International Registered Report Identifier (IRRID)DERR1-10.2196/43376

Evidence suggests an involvement of hypothalamic-pituitary-adrenal (HPA) axis dysregulation in the development and maintenance of fibromyalgia syndrome (FMS). However, studies on the stress response via the HPA-axis in individuals with FMS show conflicting results. To better understand the relationship between FMS and HPA-axis dysregulation, we (1) systematically summarized the current level of evidence on HPA biomarkers in individuals with FMS compared with individuals without and (2) evaluated whether FMS is associated with a specific pattern of HPA dysregulation. The main outcome measures were cortisol, adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH), epinephrine, and norepinephrine. A systematic search of MEDLINE, EMBASE, and PsychMed yielded 47 studies eligible for meta-analysis, including 1465 individuals with FMS and 1192 FMS-free controls. No main effect of FMS was found on altered levels of blood cortisol, ACTH, CRH, and epinephrine. Compared with controls, salivary and urinary cortisol levels were decreased in individuals with FMS, whereas blood levels of norepinephrine were increased. However, heterogeneity of data was high with significant evidence for publication bias. Overall, the data are compatible with association of FMS with adrenocortical hypofunction in the presence of increased sympathetic tone. However, the data are partially contradictory, so it must be assumed that the data are highly dependent on the respective study designs, patient samples, and analytical methods and do not necessarily demonstrate an abnormal HPA-axis function in FMS.

Although psychosocial factors have a profound impact on the experience of pain and pain recovery, the transfer to clinical application has so far been insufficient. With this article, a task force of the special interest group "Psychosocial Aspects of Pain" of the German Pain Society (Deutsche Schmerzgesellschaft e. V.) would like to draw attention to the considerable discrepancy between existing scientific evidence on the importance of psychosocial factors in the development of chronic pain disorders and the translation of these findings into the care of pain patients. Our objective is a stronger integration of psychological and psychosomatic expertise in pain treatment and research, as well as the improvement of structural and institutional conditions, to achieve an increased consideration of psychosocial aspects. In this way, modern, integrative and complex pain concepts can reach the patient. Based on these fundamental findings on the importance of psychosocial factors in pain and pain treatment, implications for the transfer to clinic and further research will be shown.

The main focus of this paper is to describe the development and current state of policy, research and implementation of patient-centered care (PCC) and shared decision-making (SDM) in Germany.What is the current state in health policy? Since 2013, the Law on Patients' Rights has standardized all rights and responsibilities regarding medical care for patients in Germany. This comprises the right to informed decisions, comprehensive and comprehensible information, and decisions based on a clinician-patient partnership. In addition, reports and action plans such as the German Ethics Council's report on patient well-being, the National Health Literacy Action Plan, or the National Cancer Plan emphasize and foster PCC and SDM on a policy level. There are a number of public organizations in Germany that support PCC and SDM.How are patients and the public involved in health policy and research? Publishers and funding agencies increasingly demand patient and public involvement. Numerous initiatives and organizations are involved in publicizing ways to engage patients and the public. Also, an increasing number of public and research institutions have established patient advisory boards.How is PCC and SDM taught? Great progress has been made in introducing SDM into the curricula of medical schools and other health care providers' (HCPs) schools (e. g., nursing, physical therapy).What is the German research agenda? The German government and other public institutions have constantly funded research programs in which PCC and SDM are important topics. This yielded several large-scale funding initiatives and helped to develop SDM training programs for HCPs in different fields of health care and information materials. Recently, two implementation studies on SDM have been con-ducted.What is the current uptake of PCC and SDM in routine care, and what implementation efforts are underway? Compared to the last country report from 2017, PCC and SDM efforts in policy, research and education have been intensified. However, many steps are still needed to reliably implement SDM in rou-tine care in Germany. Specifically, the further development and uptake of decision tools and countrywide SDM trainings for HCPs require further efforts. Nevertheless, an increasing number of decision support tools - primarily with support from health insurance funds and other public agencies - are to be imple-mented in routine care. Also, recent implementation efforts are promising. For example, reimbursement by health insurance companies of hospital-wide SDM implementation is being piloted. A necessary next step is to nationally coordinate the gathering and provision of the many PCC and SDM resources available.

Although there is growing awareness among physicians regarding chronic pain, the patient with chronic pain is often considered a complex, if not "difficult" patient in practice. Patients with chronic pain are thus at increased risk of being hastily dismissed and sent on their way. At the same time, therapeutic options are often limited and therapeutic successes not satisfying.

Obwohl die Aufmerksamkeit unter den Ärztinnen und Ärzten in Bezug auf chronische Schmerzen wächst, gilt der Patient mit chronischen Schmerzen in der Praxis oftmals als komplexer, wenn nicht sogar „schwieriger“ Patient. Patienten mit chronischen Schmerzen sind damit dem erhöhten Risiko ausgesetzt, vorschnell abgewiesen und weitergeschickt zu werden. Gleichzeitig sind die therapeutischen Möglichkeiten oftmals begrenzt und die Therapieerfolge unbefriedigend.

BACKGROUND:Cancer patients are facing a variety of treatment and other disease-related decisions. This study aims to provide insights into preferred and perceived participation roles in decision-making among patients with diverse tumors using the German Cancer Information Service (CIS). METHODS:Patients' decision-making preferences and experiences were assessed as a part of a cross-sectional survey among CIS users. An adapted version of the Control Preferences Scale (CPS) was used to assess preferred and perceived participation roles in eight different areas of medical decision-making (e.g., choice of medication, termination of treatment). Logistic regression analyses were applied to explore preference matching and to analyze associations between participation roles and sociodemographic variables. Moreover, we examined preferences and perceptions of participation roles across different decision situations. RESULTS:In the final sample (N = 1566, 64.9% female, mean age = 61.6), almost half of the patients (47.1%) preferred to take a collaborative role in decisions on treatment methods, whereas 36.3% preferred an active role and 15.9% a passive role. Collaborative role preferences frequently (40.7%) coincided with experiencing a passive role and predicted a reduced chance of a match between preferences and experiences (OR = 0.57, p = .001). A higher level of education was associated with a lower chance of preferring and perceiving a passive role (OR = 0.85, p < .01). Compared with men, women had increased odds of preferring (OR = 1.45, p < .05) and of actually taking (OR = 2.04, p < .001) a passive role in medical encounters. Preferred participation roles regarding treatment methods were highly correlated with preferences in all other decision areas (r > .50, p < .001) except decisions about family involvement. CONCLUSIONS:The study reveals well-known deficits in the fulfilment of patients' collaborative role preferences across different areas of medical decision-making in a sample of CIS users characterized by high information-seeking behavior. Participation roles were not only influenced by the patients' level of education but also by their gender. The gender effect may be more pronounced than previous studies suggest. These effects should be considered in the development of interventions to promote shared decision-making. Additionally, study results indicate that preferences for participation in decisions about treatment methods, as assessed by the CPS, can be generalized to other areas of medical decision-making.

ZusammenfassungPsychosoziale Faktoren beeinflussen Schmerzerleben und Schmerzgenesung weitreichend, trotzdem ist der Transfer in die klinische Anwendung bisher unzureichend. Mit diesem Beitrag möchte eine Arbeitsgruppe des Arbeitskreises „Psychosoziale Aspekte bei Schmerz“ der Deutschen Schmerzgesellschaft e. V. auf die erhebliche Diskrepanz zwischen bestehender wissenschaftlicher Evidenz zur Bedeutung psychosozialer Faktoren bei der Entstehung chronischer Schmerzstörungen und der Translation dieser Ergebnisse in die Versorgung von Schmerzpatienten aufmerksam machen. Unsere Ziele sind eine stärkere Integration psychologischer und psychosomatischer Expertise in die Schmerzbehandlung und -forschung sowie die Verbesserung der strukturellen und institutionellen Voraussetzungen, um zu einer vermehrten Berücksichtigung psychosozialer Aspekte zu kommen. Nur so können die modernen, integrativen und komplexen Schmerzkonzepte beim Patienten ankommen. Basierend auf diesen grundlegenden Erkenntnissen zur Bedeutung psychosozialer Faktoren bei Schmerz und Schmerzbehandlung sollen Implikationen für den Transfer in die Klinik und die weitere Forschung aufgezeigt werden.