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Benebo FO, Lukic M, Jakobsen MD, Braaten TB. Lifestyle risk factors of self-reported fibromyalgia in the Norwegian Women and Cancer (NOWAC) study. BMC Public Health 2023; 23:1967. [PMID: 37821848 PMCID: PMC10566054 DOI: 10.1186/s12889-023-16773-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/16/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND While the aetiology of fibromyalgia syndrome (FM) remains unknown, lifestyle factors have been linked to the disorder. However, there are few studies on the association between lifestyle factors and FM, thus we examine the risk of self-reported fibromyalgia given selected lifestyle factors. METHODS We used data from 75,485 participants in the Norwegian Women and Cancer study. Information on FM and the lifestyle factors body mass index (BMI), physical activity level, smoking status/intensity, and alcohol consumption were obtained from baseline and follow-up questionnaires. We used Cox proportional hazards model to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS After a median follow-up time of 10 years, we observed 2,248 cases of self-reported fibromyalgia. Overweight (BMI 25-29.9 kg/m2) and obese (BMI ≥ 30 kg/m2) women had a relative risk of 1.34 (95% CI 1.21-1.47) and 1.62 (95% CI 1.41-1.87), respectively, compared to women with normal weight (BMI 18.5-24.9 kg/m2). Very low physical activity level (1-2) was associated with a 31% higher risk of self-reported fibromyalgia (HR 1.31, 95% CI 1.09-1.57) when compared to moderate physical activity level (5-6). There was a strong dose-response relationship between smoking status/intensity and self-reported fibromyalgia (p for trend < 0.001). Compared with moderate alcohol consumption (4.0-10 g/day), the risk of self-reported FM was 72% (HR 1.72; 95% CI 1.45-2.03) higher among teetotallers, and 38% (HR 1.38, 95% CI 1.23-1.54) higher among those with low consumption (0.1-3.9 g/day). CONCLUSIONS Overweight and obesity, very low physical activity level, smoking, and alcohol consumption were associated with an increased risk of self-reported FM.
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Affiliation(s)
- Faith Owunari Benebo
- Department of Community Medicine, UiT The Artic University of Norway, Tromsø, Norway.
| | - Marko Lukic
- Department of Community Medicine, UiT The Artic University of Norway, Tromsø, Norway
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2
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Traumatic Life Experience and Pain Sensitization: Meta-analysis of Laboratory Findings. Clin J Pain 2023; 39:15-28. [PMID: 36524769 DOI: 10.1097/ajp.0000000000001082] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Psychological trauma often co-occurs with pain. This relationship has been explored using laboratory pain measures; however, findings have been mixed. Previous studies have limited operationalization of trauma (eg, posttraumatic stress disorder) or pain (eg, pain thresholds), which may contribute to conflicting results. Further, prior reviews likely underrepresent trauma experiences among people who are not receiving clinical care, limiting generalizability. MATERIALS AND METHODS We systematically reviewed the existing literature on the relationship between psychological trauma (eg, car accidents, sexual assault, childhood abuse, neglect) and laboratory pain (ie, quantitative sensory testing measures of pain threshold, intensity, summation, modulation), using inclusive criteria. The direction of the relationship between psychological trauma and pain sensitivity was evaluated, and moderation by purported pain mechanism (ie, pain detection, suprathreshold pain, central sensitization, inhibition) was explored. RESULTS Analyses were conducted using 48 studies that provided 147 effect sizes. A multivariate random-effects model with robust variance estimation resulted in a small but statistically significant overall effect size of g=0.24 (P=0.0002), reflecting a positive association between psychological trauma and enhanced laboratory pain sensitivity. Upon examination of mechanistic moderators, this relationship appears driven by effects on pain detection (g=0.28, P=0.002) and central sensitization (g=0.22, P=0.04). While effect sizes were similar across all moderators, effects on suprathreshold pain and inhibition were not statistically significant. DISCUSSION Findings demonstrate an overall pattern of trauma-related pain enhancement and point to central sensitization as a key underlying mechanism.
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Doebl S, Hollick RJ, Beasley M, Choy E, Macfarlane GJ. Comparing the Impact of Symptoms and Health Care Experiences of People Who Have and Have Not Received a Diagnosis of Fibromyalgia: A Cross-Sectional Survey Within the PACFiND Study. Arthritis Care Res (Hoboken) 2022; 74:1894-1902. [PMID: 34085414 DOI: 10.1002/acr.24723] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/08/2021] [Accepted: 06/01/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare the impact of symptoms and health care utilization of people diagnosed with fibromyalgia, people who fulfill the criteria but are not diagnosed, and people with chronic pain. METHODS We recruited people who had participated in a previous population survey across Scotland and who reported some typical fibromyalgia symptoms or had received a diagnosis of fibromyalgia. Responses to a postal questionnaire were used to define mutually exclusive groups: people who had a fibromyalgia diagnosis, who met criteria for fibromyalgia, and who had chronic pain. RESULTS Participants included 85 people with a diagnosis of fibromyalgia, 110 who met criteria for fibromyalgia, and 133 with chronic pain. The mean age across groups ranged 57-59 years, but the percentage female varied markedly: 86%, 64%, and 67%, respectively. Compared to those with chronic pain, participants with a fibromyalgia diagnosis were more likely to be out of employment due to health. An average of 3 years was needed to receive a fibromyalgia diagnosis, and more than half were diagnosed in secondary care (most commonly rheumatology). The fibromyalgia diagnosis and criteria groups were similar in terms of symptom impact, quality of life, and life satisfaction but were worse than the chronic pain group. Participants who had received a diagnosis of fibromyalgia reported the poorest health care experiences. CONCLUSION An urgent need exists for a model of care for fibromyalgia to ensure prompt diagnosis, access to evidence-based care, and long-term support, with the aim of improving function. The data suggest that diagnosis in men may be overlooked, and this finding warrants further study.
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Affiliation(s)
- Stefanie Doebl
- School of Medicine, Medical Sciences, and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Rosemary J Hollick
- School of Medicine, Medical Sciences, and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Marcus Beasley
- School of Medicine, Medical Sciences, and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | - Gary J Macfarlane
- School of Medicine, Medical Sciences, and Nutrition, University of Aberdeen, Aberdeen, UK
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Morton L, Stelfox K, Beasley M, Jones GT, Macfarlane GJ, Walker-Bone K, Hollick RJ. Enabling work participation for people with musculoskeletal conditions: lessons from work changes imposed by COVID-19: a mixed-method study. BMJ Open 2022; 12:e057919. [PMID: 35393323 PMCID: PMC8990257 DOI: 10.1136/bmjopen-2021-057919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To understand what we can learn from the impact of the COVID-19 pandemic and lockdown about what enables work participation for people with inflammatory arthritis and chronic pain conditions. DESIGN Qualitative interviews embedded within an observational questionnaire study of individuals with musculoskeletal (MSK) conditions. SETTING UK primary care (general practices), and secondary care-based rheumatology services. PARTICIPANTS Individuals with axial spondyloarthritis, psoriatic arthritis and MSK pain from three established cohorts completed an online/paper-based questionnaire (July-December 2020). A subset of respondents were selected for semistructured interviews. PRIMARY AND SECONDARY OUTCOME MEASURES The survey quantified the effects of lockdown on work circumstances. Qualitative interviews explored the impacts of these changes and the advantages and disadvantages of changes in work circumstances. RESULTS 491 people (52% female, median age 49 years) who were employed at the time of lockdown responded to the questionnaire. The qualitative analysis included 157 free-text comments on work from the questionnaire and data collected within 18 interviews.Participants reported impacts on mental and physical health, and significant financial anxieties. The impact of work changes varied depending on individual and home circumstances. Some felt forced to ignore advice to shield and continue working. The flexibility offered by home working and changes in commuting enabled greater physical activity for some, while others missed the exercise normally undertaken as part of their commute. Others reported a constant need to be 'present' online, which heightened anxiety and worsened MSK symptoms. CONCLUSION Lockdown showed that flexible working arrangements, which consider the positive and negative aspects of commuting, posture, movement, and work environment matter for work participation, and can have wider benefits in terms of health and well-being for those with long-term MSK conditions. Incorporating these into new models of work will help make the workplace more equitable and inclusive for people with long-term MSK conditions.
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Affiliation(s)
- LaKrista Morton
- Epidemiology Group, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
| | - Kevin Stelfox
- Epidemiology Group, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
| | - Marcus Beasley
- Epidemiology Group, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
| | - Gareth T Jones
- Epidemiology Group, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
| | - Gary J Macfarlane
- Epidemiology Group, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
| | - Karen Walker-Bone
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, University of Southampton, Southampton, UK
| | - Rosemary J Hollick
- Epidemiology Group, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
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Kognitive Verhaltenstherapie zur Prävention des
CWP-Syndroms? AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1547-3570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Zu den Hauptsymptomen der Fibromyalgie gehören ausgebreitete
chronische Schmerzen (chronic widespread pain/CWP), die laut
aktuellen Leitlinien primär nicht-medikamentös behandelt
werden sollten. Gute kurz- und langfristige Ergebnisse liefert da
z. B. die kognitive Verhaltenstherapie (KVT), auch wenn sie
„nur“ telefonisch durchgeführt wird. Das konnten
auch Macfarlane und seine Kollegen in einer früheren Studie
bestätigen.
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Goebel A, Andersson D, Helyes Z, Clark JD, Dulake D, Svensson C. The autoimmune aetiology of unexplained chronic pain. Autoimmun Rev 2021; 21:103015. [PMID: 34902604 DOI: 10.1016/j.autrev.2021.103015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/08/2021] [Indexed: 01/10/2023]
Abstract
Chronic pain is the leading cause of life years lived with disability worldwide. The aetiology of most chronic pain conditions has remained poorly understood and there is a dearth of effective therapies. The WHO ICD-11 has categorised unexplained chronic pain states as 'chronic primary pains' (CPP), which are further defined by their association with significant distress and/or dysfunction. The new mechanistic term, 'nociplasticic pain' has been developed to illustrate their presumed generation by a structurally intact, but abnormally functioning nociceptive system. Recently, researchers have unravelled the surprising, ubiquitous presence of pain-sensitising autoantibodies in four investigated CPP indicating autoimmune causation. In persistent complex regional pain syndrome, fibromyalgia syndrome, chronic post-traumatic limb pain, and non-inflammatory joint pain associated with rheumatoid arthritis, passive transfer experiments have shown that either IgG or IgM antibodies from patient-donors cause symptoms upon injection to rodents that closely resemble those of the clinical disorders. Targets of antibody-binding and downstream effects vary between conditions, and more research is needed to elucidate the molecular and cellular details. The central nervous system appears largely unaffected by antibody binding, suggesting that the clinically evident CNS symptoms associated with CPP might arise downstream of peripheral processes. In this narrative review pertinent findings are described, and it is suggested that additional symptom-based disorders might be examined for the contribution of antibody-mediated autoimmune mechanisms.
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Affiliation(s)
- Andreas Goebel
- Pain Research Institute, Institute for Life Course and Medical Sciences, University of Liverpool, UK and Walton Centre NHS Foundation Trust, Liverpool, UK.
| | - David Andersson
- Institute of Psychiatry, Psychology and Neuroscience, Wolfson Centre for Age-Related Disease, King's College London, UK
| | - Zsuzsanna Helyes
- Department of Pharmacology and Pharmacotherapy, Medical School & Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - J David Clark
- Anaesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA
| | | | - Camilla Svensson
- Department of Physiology and Pharmacology, Center for Molecular Medicine, Karolinska Institutet, Stockholm 171 76, Sweden
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Begum N, Taylor JR, Brown C, Rajan J, Keevil B, Pye E, Rainey T, Jones A. Morning and evening salivary cortisol levels in patients with chronic widespread pain and those at high risk. Eur J Pain 2021; 26:197-206. [PMID: 34437747 DOI: 10.1002/ejp.1854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/15/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hypothalamic-Pituitary-Adrenal (HPA) axis dysregulation has been implicated in chronic widespread pain (CWP); the hallmark of fibromyalgia (FM). This is the first study to compare HPA axis changes in individuals with CWP and those at high risk of symptom development. METHODS We sought to determine differences in morning and evening salivary cortisol levels in FM (n = 19), those at-risk (n = 20) and pain-free controls (n = 17). Risk factors included non-CWP pain, somatic symptoms, illness behaviour and sleep disturbance. We conducted the study in the absence of centrally acting medication, to address limitations of previous research. RESULTS Repeated measures ANOVA revealed significant main effects of group (p = 0.003), and time of day (p = 0.002), with no significant interaction. Cortisol levels were higher in FM (p = 0.027) and at-risk (p = 0.003) groups, compared to controls, but there was no significant difference between FM and at-risk groups. The main effect of group remained significant with sleep problems (p = 0.021) and life events (p = 0.007), but was not significant with anxiety (p = 0.076) or depression (p = 0.098) scores as covariates. With sleep problems as a covariate, cortisol levels remained significantly higher only in the at-risk group (p = 0.017). CONCLUSIONS This study indicates elevated salivary cortisol in FM and those at high risk, and identifies anxiety, depression and sleep problems as potential contributing factors. The results shed light on the dynamic relationship between stress, mood and sleep disorders and the brain's resilience to pain. SIGNIFICANCE This study examines neurobiological changes in chronic widespread pain and high risk individuals. One strength of the study is the absence of centrally acting medication. We found high salivary cortisol common to Fibromyalgia and those at risk and identified contributing factors. Our results offer insight into the early mechanistic changes underlying Fibromyalgia development and open up possibilities for early diagnosis and prevention.
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Affiliation(s)
- Nayab Begum
- Division of Neuroscience and Experimental Psychology, Human Pain Research Group, University of Manchester, Manchester, UK
| | - Jason R Taylor
- Division of Neuroscience and Experimental Psychology, Human Pain Research Group, University of Manchester, Manchester, UK
| | - Christopher Brown
- Division of Neuroscience and Experimental Psychology, Human Pain Research Group, University of Manchester, Manchester, UK.,Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Jonathan Rajan
- Division of Neuroscience and Experimental Psychology, Human Pain Research Group, University of Manchester, Manchester, UK
| | - Brian Keevil
- Department of Clinical Biochemistry, University Hospital South Manchester NHS Foundation Trust, Manchester, UK
| | - Emily Pye
- Division of Neuroscience and Experimental Psychology, Human Pain Research Group, University of Manchester, Manchester, UK
| | - Timothy Rainey
- Division of Neuroscience and Experimental Psychology, Human Pain Research Group, University of Manchester, Manchester, UK
| | - Anthony Jones
- Division of Neuroscience and Experimental Psychology, Human Pain Research Group, University of Manchester, Manchester, UK
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The Effects of Mindfulness-Based Mandala Coloring, Made in Nature, on Chronic Widespread Musculoskeletal Pain: Randomized Trial. Healthcare (Basel) 2021; 9:healthcare9060642. [PMID: 34071674 PMCID: PMC8226655 DOI: 10.3390/healthcare9060642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 11/21/2022] Open
Abstract
This study aimed to investigate the effects of mindfulness-based mandala coloring made within nature on individuals with chronic widespread musculoskeletal pain (CWP). Thirty-six participants were randomly allocated. In the experimental group, identical interventions and procedures were administered for each experiment. The control group members were untreated and remained in an urban environment. Overall, the experiment showed significant improvements in tender points (f = 8.791, p = 0.006), total stress level (f = 14.570, p = 0.001), depressive symptoms (f = 15.205, p = 0.001), anger symptoms (f = 7.263, p = 0.011) and salivary cortisol (f = 10.619, p = 0.003) in the experimental group. The results reflect that MBMC within nature is effective in reducing pain, psychological stress responses, and cortisol levels in individuals with CWP. The positive results could be a product of the experimental design rather than the treatment itself. A rigorous experimental design provides better understanding of MBMC within nature.
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Macfarlane GJ, Hollick RJ, Morton L, Heddle M, Bachmair EM, Anderson RS, Whibley D, Keenan KF, Murchie P, Stelfox K, Beasley MJ, Jones GT. The effect of COVID19 public health restrictions on the health of people with musculoskeletal conditions and symptoms: the CONTAIN study. Rheumatology (Oxford) 2021; 60:SI13-SI24. [PMID: 34009314 PMCID: PMC8244573 DOI: 10.1093/rheumatology/keab374] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/19/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To quantify the change in quality of life, disease-specific indicators, health, and lifestyle before and during the COVID19 pandemic amongst people with musculoskeletal diagnoses and symptoms. METHODS We undertook an additional follow-up of two existing UK registers involving people with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) and participants in a trial in the UK who had regional pain and were identified at high risk of developing chronic widespread pain. Participants completed the study questionnaire between July and December 2020, throughout which time there were public health restrictions in place. RESULTS 1054 people took part in the study (596 axSpA, 162 PsA, 296 regional pain). In comparison to their previous (pre-pandemic) assessment, there was an age-adjusted significant, small, decrease in quality of life measured by EQ-5D (-0.020 95% CI (-0.030, -0.009)) overall and across all population groups examined. This was primarily related to poorer mental health and pain. There was a small increase in fibromyalgia symptoms, but a small decrease in sleep problems. There was a small deterioration in axSpA disease activity, and disease-specific quality of life and anxiety in PsA participants. Predictors of poor quality of life were similar pre- and during the pandemic. The effect of lockdown on activity differed according to age, gender, and deprivation. CONCLUSION Important lessons include focussing on addressing anxiety and providing enhanced support for self-management in the absence of normal health care being available, and awareness that all population groups are likely to be affected.
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Affiliation(s)
- Gary J Macfarlane
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Rosemary J Hollick
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - LaKrista Morton
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Maureen Heddle
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Eva-Maria Bachmair
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - R Stuart Anderson
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Daniel Whibley
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Karen Forrest Keenan
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Peter Murchie
- Centre for Primary Care Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Kevin Stelfox
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Marcus J Beasley
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Gareth T Jones
- Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
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