Tailored cognitive-behavioral therapy for fibromyalgia: two case studies

A randomized controlled efficacy trial of mindfulness-based stress reduction compared with an active control group and usual care for fibromyalgia: the EUDAIMON study

Fibromyalgia (FM) syndrome represents a great challenge for clinicians and researchers because the efficacy of currently available treatments is limited. This study examined the efficacy of mindfulness-based stress reduction (MBSR) for reducing functional impairment as well as the role of mindfulness-related constructs as mediators of treatment outcomes for people with FM. Two hundred twenty-five participants with FM were randomized into 3 study arms: MBSR plus treatment-as-usual (TAU), FibroQoL (multicomponent intervention for FM) plus TAU, and TAU alone. The primary endpoint was functional impact (measured with the Fibromyalgia Impact Questionnaire Revised), and secondary outcomes included "fibromyalginess," anxiety and depression, pain catastrophising, perceived stress, and cognitive dysfunction. The differences in outcomes between groups at post-treatment assessment (primary endpoint) and 12-month follow-up were analyzed using linear mixed-effects models and mediational models through path analyses. Mindfulness-based stress reduction was superior to TAU both at post-treatment (large effect sizes) and at follow-up (medium to large effect sizes), and MBSR was also superior to FibroQoL post-treatment (medium to large effect sizes), but in the long term, it was only modestly better (significant differences only in pain catastrophising and fibromyalginess). Immediately post-treatment, the number needed to treat for 20% improvement in MBSR vs TAU and FibroQoL was 4.0 (95% confidence interval [CI] = 2.1-6.5) and 5.0 (95% CI = 2.7-37.3). An unreliable number needed to treat value of 9 (not computable 95% CI) was found for FibroQoL vs TAU. Changes produced by MBSR in functional impact were mediated by psychological inflexibility and the mindfulness facet acting with awareness. These findings are discussed in relation to previous studies of psychological treatments for FM.

Chronic pain patients can be classified into four groups: Clustering-based discriminant analysis of psychometric data from 4665 patients referred to a multidisciplinary pain centre (a SQRP study)

OBJECTIVE

To subgroup chronic pain patients using psychometric data and regress the variables most responsible for subgroup discrimination.

DESIGN

Cross-sectional, registry-based study.

SETTING AND SUBJECTS

Chronic pain patients assessed at a multidisciplinary pain centre between 2008 and 2015.

METHODS

Data from the Swedish quality registry for pain rehabilitation (SQRP) were retrieved and analysed by principal component analysis, hierarchical clustering analysis, and partial least squares-discriminant analysis.

RESULTS

Four subgroups were identified. Group 1 was characterized by low "psychological strain", the best relative situation concerning pain characteristics (intensity and spreading), the lowest frequency of fibromyalgia, as well as by a slightly older age. Group 2 was characterized by high "psychological strain" and by the most negative situation with respect to pain characteristics (intensity and spreading). Group 3 was characterized by high "social distress", the longest pain durations, and a statistically higher frequency of females. The frequency of three neuropathic pain conditions was generally lower in this group. Group 4 was characterized by high psychological strain, low "social distress", and high pain intensity.

CONCLUSIONS

The identification of these four clusters of chronic pain patients could be useful for the development of personalized rehabilitation programs. For example, the identification of a subgroup characterized mainly by high perceived "social distress" raises the question of how to best design interventions for such patients. Differentiating between clinically important subgroups and comparing how these subgroups respond to interventions is arguably an important area for further research.

Recognition of patients with medically unexplained physical symptoms by family physicians: results of a focus group study

BACKGROUND

Patients with medically unexplained physical symptoms (MUPS) form a heterogeneous group and frequently attend their family physician (FP). Little is known about how FPs recognize MUPS in their patients. We conducted a focus group study to explore how FPs recognize MUPS and whether they recognize specific subgroups of patients with MUPS. Targeting such subgroups might improve treatment outcomes.

METHODS

Six focus groups were conducted with in total 29 Dutch FPs. Two researchers independently analysed the data applying the principles of constant comparative analysis in order to detect characteristics to recognize MUPS and to synthesize subgroups.

RESULTS

FPs take into account various characteristics when recognizing MUPS in their patients. More objective characteristics were multiple MUPS, frequent and long consultations and many referrals. Subjective characteristics were negative feelings towards patients and the feeling that the FP cannot make sense of the patient's story. Experience of the FP, affinity with MUPS, consultation skills, knowledge of the patient's context and the doctor-patient relationship seemed to influence how and to what extent these characteristics play a role. Based on the perceptions of the FPs we were able to distinguish five subgroups of patients according to FPs: 1) the anxious MUPS patient, 2) the unhappy MUPS patient, 3) the passive MUPS patient, 4) the distressed MUPS patient, and 5) the puzzled MUPS patient. These subgroups were not mutually exclusive, but were based on how explicit and predominant certain characteristics were perceived by FPs.

CONCLUSIONS

FPs believe that they can properly identify MUPS in their patients during consultations and five distinct subgroups of patients could be distinguished. If these subgroups can be confirmed in further research, personalized treatment strategies can be developed and tested for their effectiveness.

Activity pacing in chronic pain: concepts, evidence, and future directions

BACKGROUND

Activity pacing (AP) is a concept that is central to many chronic pain theories and treatments, yet there remains confusion regarding its definition and effects.

OBJECTIVE

To review the current knowledge concerning AP and integrate this knowledge in a manner that allows for a clear definition and useful directions for future research.

METHODS

A narrative review of the major theoretical approaches to AP and of the empirical evidence regarding the effects of AP interventions, followed by an integrative discussion.

RESULTS

The concept of AP is derived from 2 main traditions: operant and energy conservation. Although there are common elements across these traditions, significant conceptual and practical differences exist, which has led to confusion. Little empirical evidence exists concerning the efficacy of AP as a treatment for chronic pain.

DISCUSSION

Future research on AP should be based on a clear theoretical foundation, consider the context in which the AP behavior occurs and the type of pacing problem ("underactivity" vs. "overactivity"), and should examine the impact of AP treatment on multiple clinical outcomes. We provide a provisional definition of AP and specific recommendations that we believe will move the field forward.

Do participation and personalization matter? A model-driven evaluation of an Internet-based patient education intervention for fibromyalgia patients

OBJECTIVES

To evaluate the effectiveness of an Internet-based patient education intervention, which was designed upon principles of personalization and participatory design.

METHODS

Fifteen months after the first release of the website, 209 fibromyalgia patients recruited through health professionals completed an online questionnaire to assess patients' use of the website, health knowledge, self-management behavior, and health outcomes. These constructs were combined into an a-priory model that was tested using a structural equation modeling approach.

RESULTS

Results show that the usage of certain tools of the website - designed and personalized involving the end users - impacts patients' health knowledge, which in turn impacts self-management. Improvements in self-management ultimately lower the impact of Fibromyalgia Syndrome leading to better health outcomes.

CONCLUSION

This study empirically confirmed that the adoption of a participatory approach to the design of eHealth interventions and the use of personalized contents enhance the overall effectiveness of systems.

PRACTICE IMPLICATIONS

More time and effort should be invested in involving patients in the preliminary phases of the development of Internet-based patient education interventions and in the definition of models that can guide the systems' evaluation beyond technology-related variables such as usability, accessibility or adoption.

Is Pain Intensity Really That Important to Assess in Chronic Pain Patients? A Study Based on the Swedish Quality Registry for Pain Rehabilitation (SQRP)

BACKGROUND

Incorporating the patient's view on care and treatment has become increasingly important for health care. Patients describe the variety of consequences of their chronic pain conditions as significant pain intensity, depression, and anxiety. We hypothesised that intensities of common symptoms in chronic pain conditions carry important information that can be used to identify clinically relevant subgroups. This study has three aims: 1) to determine the importance of different symptoms with respect to participation and ill-health; 2) to identify subgroups based on data concerning important symptoms; and 3) to determine the secondary consequences for the identified subgroups with respect to participation and health factors.

METHODS AND SUBJECTS

This study is based on a cohort of patients referred to a multidisciplinary pain centre at a university hospital (n = 4645, participation rate 88%) in Sweden. The patients answered a number of questionnaires concerning symptoms, participation, and health aspects as a part of the Swedish Quality Registry for Pain Rehabilitation (SQRP).

RESULTS

Common symptoms (such as pain intensity, depression, and anxiety) in patients with chronic pain showed great variability across subjects and 60% of the cohort had normal values with respect to depressive and anxiety symptoms. Pain intensity more than psychological symptoms showed stronger relationships with participation and health. It was possible to identify subgroups based on pain intensity, depression, and anxiety. With respect to participation and health, high depressive symptomatology had greater negative consequences than high anxiety.

CONCLUSIONS

Common symptoms (such as pain intensity and depressive and anxiety symptoms) in chronic pain conditions carry important information that can be used to identify clinically relevant subgroups.

Behavior change, acceptance, and coping flexibility in highly distressed patients with rheumatic diseases: feasibility of a cognitive-behavioral therapy in multimodal rehabilitation

OBJECTIVE

To describe the development and feasibility of the integration of a cognitive-behavioral therapy (CBT) within a multimodal rehabilitation program for highly distressed patients with rheumatic diseases.

METHODS

Development included the detailed specification of the theoretical and empirical-based underpinnings of the CBT and the comprehensive description of its design and content. Feasibility was assessed by percentage of eligible patients, attrition and attendance rates, and patient satisfaction.

RESULTS

The developed CBT component seeks to decrease psychological distress and improve activities and participation across multiple life domains by accomplishing behavior change, acceptance, and coping flexibility. Motivational interviewing was applied to endorse patients' own reasons to change. Forty percent (35/87) of the eligible patients were admitted to the program. Attendance rate (>95%) was high. Patient satisfaction ranged from 6.8 to 8.0 (10-point scale).

CONCLUSION

Integrating CBT within a multimodal rehabilitation program is feasible. An acceptable proportion of the intended patient sample is eligible and patient's attendance and satisfaction is high.

PRACTICE IMPLICATIONS

Patients with impaired physical and psychosocial functioning despite adequate medical treatment pose a great challenge. Their treatment outcome may be improved by screening and selecting highly distressed patients and offering them a CBT embedded in multimodal rehabilitation program.

Cognitive-behavioral mechanisms in a pain-avoidance and a pain-persistence treatment for high-risk fibromyalgia patients

OBJECTIVE

The heterogeneity of cognitive-behavioral patterns in patients with fibromyalgia (FM) has been proposed to underlie the variability in treatment outcomes. It has previously been shown that pain-avoidance and pain-persistence treatments tailored to the patient's pattern are effective in improving physical and psychological functioning and overall impact in high-risk patients with heightened psychological distress. In the present study, the cognitive-behavioral effects of these treatments were evaluated to provide insight into the main proposed mechanisms, specifically pain-avoidance behaviors and activity pacing in the pain-avoidance and pain-persistence treatments, respectively.

METHODS

High-risk FM patients were classified into 2 groups, pain avoidance and pain persistence, and randomized in groups to the relevant treatment or waiting-list control condition. The pain-avoidance and pain-persistence treatments both comprised 16 twice-weekly sessions of cognitive-behavioral therapy and exercise training. Cognitive--behavioral factors assessed at pre- and posttreatment and 6 months of followup were evaluated using linear mixed models.

RESULTS

A significant treatment effect was found for pain-avoidance behavior in the pain-avoidance treatment and for activity pacing in the pain-persistence treatment, showing improvements in the treatment condition relative to the controls. Furthermore, the effect on functioning was mediated by changes in pain-avoidance behavior in the pain-avoidance treatment and by changes in activity pacing in the pain-persistence treatment. Both treatments also showed significant improvements in other relevant cognitive-behavioral factors.

CONCLUSION

Both the pain-avoidance and pain-persistence treatments are effective in improving cognitive-behavioral factors in high-risk FM patients. Pain-avoidance behavior and activity pacing might be important mediating mechanisms for beneficial outcomes in pain-avoidance and pain-persistence treatments, respectively.

Tailored cognitive-behavioral therapy and exercise training for high-risk patients with fibromyalgia

OBJECTIVE

The treatment of patients with fibromyalgia (FM), a high-prevalence chronic pain condition with a high impact on both patients and society, poses a great challenge to clinicians due to a lack of effective treatments. In view of the large individual variability in outcome, selecting patients at risk of long-term dysfunction and offering tailored treatment may be promising for beneficial treatment effects.

METHODS

High-risk patients were selected and classified into 2 groups (pain-persistence and pain-avoidance groups) and subsequently randomized in groups to either a treatment condition (TC) or a waiting list control condition (WLC). Treatment consisted of 16 sessions of cognitive-behavioral therapy (CBT) and exercise training in groups, tailored to the patient's specific cognitive-behavioral pattern, delivered within 10 weeks. Physical and psychological functioning and impact of FM were assessed at baseline, posttreatment, and 6-month followup. Treatment effects were evaluated using a linear mixed model.

RESULTS

The treatment effects were significant for all primary outcomes, showing significant differences in physical (pain, fatigue, and functional disability) and psychological (negative mood and anxiety) functioning, and impact of FM for the TC in comparison with the WLC. Effect sizes in the TC were overall large, and reliable change indices indicated a clinically relevant improvement among the TC.

CONCLUSION

The presented results demonstrate for the first time that tailored CBT and exercise training for high-risk patients with FM is effective in improving short- and long-term physical and psychological functioning, indicating that tailoring treatment is likely to promote beneficial outcomes in FM and reduce the burden for patients and society.

Does Exercise Benefit Fibromyalgia?

This review discusses evidence-based perspectives on the potential benefits of exercise for fibromyalgia. Future directions for inquiry and clinical management also are addressed.

Risk factors for longer term psychological distress in well-functioning fibromyalgia patients: a prospective study into prognostic factors

OBJECTIVE

Psychological distress is a key risk factor for long-term complaints in fibromyalgia (FM). Prognostic factors for psychological distress might facilitate an early identification of patients at risk to help prevent long-term dysfunction, especially for the relatively well-functioning patients showing little distress who are usually not considered for treatment. This study hence examines potential prognostic factors in this subgroup.

METHODS

Psychological distress, physical functioning, illness cognitions (helplessness, acceptance), pain-avoidance factors (passive pain-coping, fear of pain, hypervigilance), and social factors (social support, social reinforcement) was assessed in 78 low-distress FM patients at baseline and after a mean of 9 months (SD=3.3).

RESULTS

Baseline physical functioning did not predict changes in psychological distress, whereas a higher level of hypervigilance, less acceptance, and less perceived social support predicted an increase in psychological distress at follow-up.

CONCLUSION

Illness cognitions, pain-avoidance factors, and social support can be considered as prognostic factors predicting changes in psychological distress in FM. More research is needed to investigate additional factors that could also be implicated (e.g. personality factors, stressful events).

PRACTICE IMPLICATIONS

Timely assessment of illness cognitions, pain-avoidance factors, and social support may help identify subgroups of relatively well-functioning FM patients at risk of longer term aggravated psychological distress.

An individually tailored treatment programme for improved oral hygiene: introduction of a new course of action in health education for patients with periodontitis

OBJECTIVES

To describe and evaluate an individually tailored treatment programme based on a behavioural medicine approach to oral hygiene self-care for patients with chronic periodontitis.

METHODS

Two experimental single-case studies with multiple-baseline design across different self-administered oral hygiene behaviours were conducted. Cognitive Behavioural techniques were used to organize the strategies for the intervention and the approach to counselling was inspired by and structured in accordance with Motivational Interviewing. The central features in the programme were the individual analysis of knowledge and oral hygiene habits, individually set goals for oral hygiene behaviour, practice of manual dexterity for oral hygiene aids, continuous self-monitoring of the behaviour and prevention of relapse.

RESULTS

Both participants reached the predecided criteria for clinical significance in reducing plaque and bleeding on probing. Reductions of periodontal probing depth were achieved as well. The positive results remained stable throughout the 2-year study period.

CONCLUSION

The successful application of this educational model suggests that it could be used as a method for tailoring interventions targeted to oral hygiene for patients with periodontal conditions. The programme will now be tested in a larger randomized controlled trial.