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

[Effects of a multimodal inpatient treatment for patients with fibromyalgia syndrome at the Rhineland-Palatinate Acute Rheumatology Center]

INTRODUCTION

Fibromyalgia syndrome (FMS) is a complex condition that is often refractory to therapy and is associated with impaired quality of life. In some studies, multimodal rheumatological treatment has been shown to be an effective therapy option for patients with systemic-inflammatory and degenerative rheumatic diseases. However, the effects of this therapeutic approach have not been sufficiently investigated in patients with FMS. Therefore, the aim of this study was to examine the effect of a concise 9‑ to 10-day inpatient multimodal fibromyalgia treatment (MFT) using patient-reported outcomes in a German cohort.

METHODS

The effects of MFT were assessed using visual analog scales (VAS) for pain (P) and subjective disease activity (DA), questionnaires measuring everyday functional capacity (Health Assessment Questionnaire [HAQ], Funktions-Fragebogen-Hannover [FFbH, Hannover Functional Ability Questionnaire]), and pharmacotherapy at three time points (Visit 1: beginning of multimodal therapy, Visit 2: end of MFT, and Visit 3: 3 months after Visit 2).

RESULTS

Sixty-one patients were enrolled in the study at the Rhineland-Palatinate Acute Rheumatology Center. Under MFT, a significant improvement in VAS (P) and VAS (DA) was observed between the start and end of treatment (Visit 2 versus Visit 1: median decrease from 7 to 5, p < 0.001, for both VAS [P] and VAS [DA]). Additionally, comparison of the other two assessment points showed a change in VAS (P) (Visit 3 versus Visit 1: median decrease from 7 to 6, p = 0.041, and Visit 3 versus Visit 2: median increase from 5 to 6, p = 0.004). However, there were no significant differences in FFbH and HAQ parameters among the three visits. Examination of the subgroup of patients whose medication therapy was not intensified during hospitalization also showed significant improvements in VAS (P) and VAS (DA) between the start and end of MFB (Visit 2 versus Visit 1: median decrease from 7 to 4, p < 0.001, for VAS [P] and median decrease from 6.25 to 4, p = 0.002, for VAS [DA]).

CONCLUSION

These findings indicate a demonstrable benefit to patients of MFT regarding both pain and subjective disease activity. Furthermore, pain relief was even observed 3 months after the end of therapy. This shows the high value of this therapeutic approach to treating patients with FMS.

Is personalization of psychological pain treatments necessary? Evidence from a Bayesian variance ratio meta-analysis

ABSTRACT

This is the first study to empirically determine the potential for data-driven personalization in the context of chronic primary pain (CPP). Effect sizes of psychological treatments for individuals with CPP are small to moderate on average. Aiming for better treatment outcomes for the individual patient, the call to personalize CPP treatment increased over time. However, empirical evidence that personalization of psychological treatments can optimize treatment outcomes in CPP is needed. This study seeks to estimate heterogeneity of treatment effect for cognitive behavioral therapy (CBT) as the psychological treatment approach for CPP with the greatest evidence base. For this purpose, a Bayesian variance ratio meta-regression is conducted using updated data from 2 recently published meta-analyses with randomized controlled trials comparing CBT delivered face-to-face to treatment-as-usual or waiting list controls. Heterogeneity in patients with CPP would be reflected by a larger overall variance in the post-treatment score compared with the control group. We found first evidence for an individual treatment effect in CBT compared with the control group. The estimate for the intercept was 0.06, indicating a 6% higher variance of end point values in the intervention groups. However, this result warrants careful consideration. Further research is needed to shed light on the heterogeneity of psychological treatment studies and thus to uncover the full potential of data-driven personalized psychotherapy for patients with CPP.A Bayesian variance ratio meta-regression indicates empirical evidence that data-driven personalized psychotherapy for patients with chronic primary pain could increase effects of cognitive behavioral therapy.

A Comparative Study on the Pain Threshold Experienced by Fibromyalgia Patients Following Acute SARS-CoV-2 Infection

Significant gaps remain in the understanding of the etiology and pathogenesis of fibromyalgia (FM), and the COVID-19 pandemic has introduced even more unknowns. Social factors specific to that period, the viral infection itself, and/or vaccination are additional elements that can complicate the progression of the disease or the response to treatment. Aim: The primary hypothesis to be evaluated in this study is that an acute COVID-19 infection, even when considered recovered, may induce changes in the response to non-pharmacological treatment in FM patients, particularly concerning pain. Results: We included 128 patients diagnosed with FM before the pandemic began. The patients were divided based on their history of acute SARS-CoV-2 infection and COVID-19 vaccination status. All patients followed the same rehabilitation program (cognitive therapy, kinesitherapy). Perceived pain: The non-COVID-19 patient groups showed a statistically significant reduction in pain at the final evaluation compared to patients with a history of acute SARS-CoV-2 infection (p < 0.001). Algometric evaluation: Patients without COVID-19 infection and that were vaccinated exhibited the best improvement in pain threshold, both across evaluation times (p < 0.001) and compared to any of the other three groups studied (p < 0.001). Using the WHYMPI questionnaire, the same group of patients (those not having experienced acute COVID-19 and who were vaccinated) was the only group with a statistically significant improvement in pain severity (p = 0.009). In conclusion, to control and improve FM pain symptoms, in addition to appropriate medication, we propose paying additional attention to the history of acute SARS-CoV-2 infection and the COVID-19 vaccination status.

Development and impact of a tailored eHealth resource on fibromyalgia patient's self-management and self-efficacy: A mixed methods approach

Aim

To develop an eHealth resource to support fibromyalgia patients and explore it for usability and impact on their self-management and self-efficacy.

Background

Fibromyalgia is a complex, non-progressive chronic condition characterised by a bewildering array of symptoms for patients to self-manage. International guidelines recommend patients receive illness-specific information once diagnosed to promote self-management and improve health-related quality of life.

Design

A 3-phase mixed methods exploratory sequential design.

Methods

Qualitative interviews explored the information and self-management needs of fibromyalgia patients attending a large tertiary hospital in Dublin. Identified themes together with an extensive review of the literature of interventions proven to be impactful by patients with fibromyalgia were utilised in the design and development of the eHealth resource. The resource was tested for usability and impact using pre and post-intervention outcomes measures.

Results

Patient interviews highlighted a lack of easy accessible evidenced information to support self-management implicating the urgent need for a practical solution through development of a tailored eHealth resource. Six themes emerged for inclusion; illness knowledge, primary symptoms, treatment options, self-management strategies, practical support and reliable resources. Forty-five patients who tested the site for usability and impact demonstrated a statistically significant improvement in self-efficacy after 4 weeks access with a medium positive effect size. Patients with the most severe fibromyalgia impact scores pre-intervention demonstrated the most improvement after 4 weeks. Patients gave the resource a System Usability Score A rating, highly recommending it for fellow patients diagnosed with fibromyalgia.

Conclusions

The study demonstrated how the development of a novel eHealth resource positively impacted fibromyalgia patients' self-efficacy to cope with this debilitating condition.

Impact

This study suggests that access to eHealth can positively impact patients self-efficacy, has the potential to be a template for eHealth development in other chronic conditions, supporting advanced nurse practitioners working in chronic disease management.

"Don't need [therapy]! Not necessary, that's what we're for!": Does content from fibromyalgia Facebook peer support groups emulate psychological flexibility principles?

Objective

Many persons with fibromyalgia (FM) use online peer support groups (OPSGs) to address unmet emotional or psychological needs. Some OPSG members have suggested that participation in an OPSG is a viable substitute for professional psychological services, however, no published research exploring this claim was identified.

Methods

Discussion content collected from three Facebook FM OPSGs was thematically analyzed to explore whether the content posted in FM OPSGs emulated content consistent with the psychological flexibility model underlying Acceptance and Commitment Therapy (ACT) - an evidence-based psychotherapy for chronic pain conditions.

Results

The content posted in OPSGs did not emulate and often contradicted the core psychological flexibility processes or skills emphasized in ACT programs.

Conclusion

Participation in an FM OPSG should be approached cautiously. Content from the FM OPSGs should not be considered a substitute for professionally delivered ACT, although participation may provide emotional support to help individuals move towards readiness for active psychotherapy.

Innovation

This research represents a novel application of the psychological flexibility model underlying ACT to assess the potential therapeutic value of a peer support community. Additionally, it is the first to clarify that content in FM OPSGs is not aligned with psychological flexibility processes.

Self-regulation of effort for a better health-related quality of life: a multidimensional activity pacing model for chronic pain and fatigue management

PURPOSE

To propose a comprehensive multidimensional model of activity pacing that improves health-related quality of life and promotes sustained physical activity engagement among adults with chronic conditions.

MATERIALS AND METHODS

A narrative review was conducted to examine the existing literature on activity pacing, health-related quality of life, pain and fatigue management, and physical activity promotion in chronic conditions.

RESULTS

The literature revealed a lack of a cohesive approach towards a multidimensional model for using activity pacing to improve health-related quality of life. A comprehensive multidimensional model of activity pacing was proposed, emphasizing the importance of considering all aspects of pacing for sustained physical activity engagement and improved health-related quality of life. The model incorporates elements such as rest breaks, self-regulatory skills, environmental factors, and effective coping strategies for depression/anxiety. It takes into account physical, psychological, and environmental factors, all of which contribute significantly to the enhancement of health-related quality of life, physical function, and overall well-being, reflecting a holistic approach.

CONCLUSIONS

The model offers guidance to researchers and clinicians in effectively educating patients on activity pacing acquisition and in developing effective interventions to enhance physical activity engagement and health outcomes among adults with chronic conditions. Additionally, it serves as a tool towards facilitating discussions on sustained physical activity and a healthy lifestyle for patients, which can eventually lead to improved quality of life.

Personalized pain management: Is it time for process-based therapy for particular people with chronic pain?

BACKGROUND AND OBJECTIVE

Psychological treatments for chronic pain have helped many people around the world. They are among the most researched and best evidenced treatments a person can receive when they have persistent, disabling and distressing pain. At the same time, improvements in the effectiveness of these treatments appear to be at a standstill. This may be due to an inherent lack of generalizability from aggregated group data to the individual, limited utility of our current schemes for categorizing people with pain conditions, faced with their inherent heterogeneity, our relatively coarse categories of treatment types and focus on treatment packages rather than individual methods, and our current failures to find adequate predictors of outcome, or to assign people their best-suited treatment methods, based on group data. In this review, it is argued that the development and examination of truly personalized treatment is a next logical step to create progress and improve the results people achieve.

METHODS

Key research studies pertaining to psychological treatments, treatment outcome, heterogeneity in chronic pain, prediction of treatment outcome, subtyping and treatment tailoring are reviewed.

RESULTS AND CONCLUSION

It is suggested that development of future treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, based on contextually sensitive ongoing assessment. Knowledge and practical solutions needed to make process-based therapy for chronic pain happen are discussed.

SIGNIFICANCE

Psychological approaches to chronic pain have been highly successful in the past but improvement in the effectiveness of these over time is slow to nonexistent. It is argued here that this has happened due to a failure to adequately consider the individual. Future psychological treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, grounded in ongoing contextually sensitive assessment.

"I've got a spring in my step" participants experience of action observation therapy and eccentric exercises, a telehealth study for mid-portion Achilles Tendinopathy: a qualitative study

BACKGROUND

Quantitative research has dominated the field of Achilles Tendinopathy. The use of qualitative research allows in-depth exploration of participants' perspectives, offering great insight in the evaluation of a trial's processes, particularly when exploring a novel intervention such as Action Observation Therapy combined with eccentric exercises which has not been previously researched. This study aimed to qualitatively explore participants' experiences of partaking in a telehealth study including the acceptability of the intervention, motivators for participation, and perspectives on the trial processes.

METHOD

A thematic analysis as guided by Braun and Clarke was used to analyse the semi-structured interviews conducted on a purposive sample of participants with mid-portion Achilles Tendinopathy who recently completed a pilot feasibility study. The study adhered to the criteria for reporting qualitative research guidelines (COREQ).

RESULTS/DISCUSSION

Sixteen participants were interviewed. The five themes identified were: (i) The impact of Achilles Tendinopathy is commonly not prioritised with 'The acceptance and minimisation of pain' as a sub-theme (ii) Therapeutic alliance has the greatest impact on support (iii) Factors which influenced adherence (iv) Action Observation Therapy is valued and recommended (v) Recommendations for future interventions.

CONCLUSION

This study provides insightful recommendations around; exploring the use of Action Observation Therapy in Achilles Tendinopathy, the relative importance of therapeutic alliance rather than mode of therapy delivery, and that sufferers of Achilles Tendinopathy may not prioritise health seeking for this condition.

Identifying Chronic Pain Subgroups in Pediatric Sickle Cell Disease: A Cluster-Analytic Approach

OBJECTIVES

Youth with sickle cell disease (SCD) and chronic pain, defined in this study as pain on most days for 3 months, experience variability in daily pain and physical and psychosocial functioning. This study aimed to (1) empirically derive chronic pain subgroups based on pain characteristics among youth with chronic SCD pain; and (2) investigate derived subgroups for differences in sociodemographics, clinical characteristics, and psychosocial and functional outcomes.

MATERIALS AND METHODS

Youth with chronic SCD pain (n=62, Mage =13.9, SD=2.5, 10 to 18 y; 58% female, 60% HbSS) completed a battery of questionnaires. Clinical characteristics (eg, medications, treatments) and health care utilization were abstracted from electronic medical records. Hierarchical cluster analysis informed the number of clusters at the patient level. k-means cluster analysis used multidimensional pain assessment to identify and assign patients to clusters.

RESULTS

Cluster 1 (n=35; Moderate Frequency, Moderate Pain) demonstrated significantly lower worst pain intensity, number of pain days per month, number of body sites affected by pain, and pain quality ratings. Cluster 2 (n=27; Almost Daily, High Pain) reported high ratings of worst pain intensity, almost daily to daily pain, greater number of body sites affected by pain, and higher ratings of pain quality (all P 's <0.05). There were no differences between subgroups by sociodemographics, clinical characteristics, or health care utilization. The Almost Daily, High Pain subgroup reported significantly higher pain interference, depressive symptoms, and pain catastrophizing than the Moderate Frequency, Moderate Pain subgroup.

DISCUSSION

Identifying chronic SCD pain subgroups may inform tailored assessment and intervention to mitigate poor pain and functional outcomes.

Review of Fibromyalgia (FM) Syndrome Treatments

BACKGROUND

Fibromyalgia (FM) is a disease characterized by widespread musculoskeletal chronic pain that impairs the patient's quality of life and is considered a somatization disorder. The symptoms of the disease also affect the patient mentally, mainly since invisible pain is the only thing that indicates its existence. A typical symptom that characterizes FM patients is the lack of acceptance of the disease since its pathophysiology is not elucidated, hence the deficiencies in its management, or rather, cognitively, the belief that there is no disease to manage. The current paper aims to shed light on the new treatment methods at a holistic level, that is, cognitive, physical, and pharmacological therapies.

METHOD

A literature review was carried out that discusses treatment methods that help alleviate the pain, accept it, and manage the symptoms of the disease.

RESULTS

FM symptoms can be treated by taking a broad view of treatment that will include a response to the mind through pain management, response to the body through physical activity, and response to the pain through pharmacological treatment.

CONCLUSIONS

Today, there is an evolutionary view that accepts FM and chronic pain diseases as syndromes in which the pain is the disease; therefore, the response to this disease can be applied through three channels: physical, bodily, and mental.

Association Between Step Count Measured With a Smartphone App (Pain-Note) and Pain Level in Patients With Chronic Pain: Observational Study

Background

Chronic pain is the leading cause of disability, affecting between 20% and 50% of the global population. The key recommended treatment is physical activity, which can be measured in daily life using a pedometer. However, poor adherence to pedometer use can result in incorrect measurements. Furthermore, only a few studies have investigated a possible curvilinear association between physical activity and chronic pain.

Objective

In this study, we developed the Pain-Note smartphone app to collect real-world data on step count, using the smartphone’s built-in pedometer. The aims of our research are (1) to evaluate the association between daily step count and pain level among patients with chronic pain and (2) determine if the association between daily step count and pain level was curvilinear.

Methods

We conducted a cross-sectional study based on step count data collected with the app and on the results of questionnaires, which measured the duration and intensity of pain, the widespread pain index, the symptom severity score, and the insomnia severity scale, including 7 questions for symptoms of depression. We analyzed the association between step count and pain level as a nonlinear relationship using a restricted cubic spline model. A prespecified subgroup analysis was also conducted based on fibromyalgia criteria.

Results

Between June 1, 2018, and June 11, 2020, a total of 6138 records were identified, of which 1273 were analyzed. The mean age of the participants was 38.7 years, 81.9% (1043/1273) were female, and chronic pain was present for more than 5 years in 43.2% (550/1273) of participants. Participants in the third and fourth quartiles for step count (more than 3045 and 5668 steps a day, respectively) showed a significant positive association between higher step count and lower numerical pain rating scale (mean difference –0.43, 95% CI –0.78 to –0.08, P=.02; –0.45; 95% CI –0.8 to –0.1, P=.01, respectively) than those in the first quartile (less than or equal to 1199 steps a day). The restricted cubic spline model for the association between step count and pain scale displayed a steep decline followed by a moderate decrease as the step count increased; the inflection point was 5000 steps. However, this association was not observed among participants who met the fibromyalgia criteria (491/1273), who showed a steep positive increase below 2000 steps. Data were collected between June 1, 2018, and June 11, 2020, and were analyzed on November 18, 2021.

Conclusions

Step count measured with the Pain-Note app showed a nonlinear association with pain level. Although participants with and without fibromyalgia showed a negative correlation between step count and pain level, participants who meet the criteria for fibromyalgia may present a different relationship between walking and pain perception compared to those in the general chronic pain population.

Feasibility of concussion rehabilitation approaches tailored to psychological coping styles: A randomized controlled trial

OBJECTIVE

To evaluate the feasibility of a clinical trial involving participants with concussion randomized to treatments designed to address fear avoidance or endurance coping, which are risk factors for disability. A secondary objective was to evaluate whether each treatment could effect selective change on targeted coping outcomes.

DESIGN

Randomized controlled trial.

SETTING

Outpatient concussion clinics.

PARTICIPANTS

73 adults (M=42.5 years old) who had persistent post-concussion symptoms and high avoidance or endurance behavior were enrolled at M=12.9 weeks post injury. 10 participants did not complete treatment.

INTERVENTIONS

Participants were randomized to an interdisciplinary rehabilitation program delivered via videoconferencing and tailored to avoidance coping (graded exposure therapy; GET) or endurance coping (operant condition-based pacing strategies plus mindfulness training; Pacing+).

MAIN OUTCOME MEASURES

Feasibility outcomes included screening efficiency, accrual, credibility, treatment fidelity, adherence, and retention. Avoidance was measured with the Fear Avoidance Behavior after Traumatic Brain Injury questionnaire and endurance behavior with the Behavioral Response to Illness Questionnaire.

RESULTS

Screening efficiency, or the proportion of clinic patients who were assessed for eligibility, was 44.5% (275/618). 65.8% (73/111) of eligible patients were randomized (n=37 to GET and n=36 to Pacing+), meeting accrual targets. 91.7% (55/60) of participants perceived treatment as credible. Therapists covered M=96.8% of essential prescribed elements, indicating excellent fidelity. The majority (71.2%; 47/66) of participants consistently attended treatment sessions and completed between-session homework. Retention was strong, with 65 of 73 (89%) randomized participants completing the outcome assessment. GET was associated with greater post-treatment reductions in avoidance behavior compared to Pacing+ (Cohen's d_{repeated measures} = 0.81), whereas the treatment approach-specific effect of Pacing+ on endurance behavior was less pronounced (Cohen's d_{repeated measures} = 0.39).

CONCLUSIONS

Findings support a future efficacy-focused clinical trial. GET has the potential to selectively reduce fear avoidance behavior after concussion, and, via this mechanism, to prevent or reduce disability.

Is Irritable Bowel Syndrome Considered as Comorbidity in Clinical Trials of Physical Therapy Interventions in Fibromyalgia? A Scoping Review

Evidence supports the presence of comorbid conditions, e.g., irritable bowel syndrome (IBS), in individuals with fibromyalgia (FM). Physical therapy plays an essential role in the treatment of FM; however, it is not currently known whether the IBS comorbidity is considered in the selection criteria for clinical trials evaluating physiotherapy in FM. Thus, the aim of the review was to identify whether the presence of IBS was considered in the selection criteria for study subjects for those clinical trials that have been highly cited or published in the high-impact journals investigating the effects of physical therapy in FM. A literature search in the Web of Science database for clinical trials that were highly cited or published in high-impact journals, i.e., first second quartile (Q1) of any category of the Journal Citation Report (JCR), investigating the effects of physical therapy in FM was conducted. The methodological quality of the selected trials was assessed with the Physiotherapy Evidence Database (PEDro) scale. Authors, affiliations, number of citations, objectives, sex/gender, age, and eligibility criteria of each article were extracted and analyzed independently by two authors. From a total of the 412 identified articles, 20 and 61 clinical trials were included according to the citation criterion or JCR criterion, respectively. The PEDro score ranged from 2 to 8 (mean: 5.9, SD: 0.1). The comorbidity between FM and IBS was not considered within the eligibility criteria of the participants in any of the clinical trials. The improvement of the eligibility criteria is required in clinical trials on physical therapy that include FM patients to avoid selection bias.

Morning and evening salivary cortisol levels in patients with chronic widespread pain and those at high risk

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.

Pain interference may be an important link between pain severity, impairment, and self-reported disability in participants with wrist/hand pain

STUDY DESIGN

Cross-sectional.

INTRODUCTION

Pain severity, sensory and motor impairment, and psychological (distress and anxiety) and social factors have previously been related to self-reported disability in persons with wrist and hand pain.

PURPOSE OF THE STUDY

The purpose of this study to determine the relative contribution of pain severity, measures of impairment (sensory and motor function), psychosocial factors, and pain interference on self-reported disability experienced by persons with heterogeneous orthopedic injuries and conditions of the wrist and hand.

METHODS

Measures of disability and pain severity as well as measures of sensory (pressure pain thresholds, joint position sense), motor (grip strength, Purdue pegboard), and cognitive performance (Stroop test) and psychosocial variables related to pain and participation (West Haven-Yale Multidimensional Pain Inventory) were administered to 60 participants with wrist and hand pain. Pearson product correlations controlled for age and sex, and multiple linear regression was performed to determine the relationship between measures of impairment, pain severity, psychosocial variables, and pain interference with self-reported disability assessed with the Disability of Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

The best-fitting regression model with DASH scores entered as the dependent variable (F_4,50 = 28.8, P < .01) included MPI Pain Interference (β = -0.54), Life Control (β = -0.16), Purdue pegboard scores (β = -0.32), and Stroop test times (β = 0.21). Pain Interference had the strongest correlation with self-reported disability (adjusted R² = 0.67, P < .01).

CONCLUSION

Pain interference appears to be an important factor explaining the link between impairment, pain severity, and self-reported disability. Addressing pain interference may be important to improve outcomes in this population.

Self-management for chronic widespread pain including fibromyalgia: A systematic review and meta-analysis

BACKGROUND

Chronic widespread pain (CWP) including fibromyalgia has a prevalence of up to 15% and is associated with substantial morbidity. Supporting psychosocial and behavioural self-management is increasingly important for CWP, as pharmacological interventions show limited benefit. We systematically reviewed the effectiveness of interventions applying self-management principles for CWP including fibromyalgia.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Central Register of Controlled Trials and the WHO International Clinical Trials Registry were searched for studies reporting randomised controlled trials of interventions adhering to self-management principles for CWP including fibromyalgia. Primary outcomes included physical function and pain intensity. Where data were sufficient, meta-analysis was conducted using a random effects model. Studies were narratively reviewed where meta-analysis could not be conducted Evidence quality was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluations) (PROSPERO-CRD42018099212).

RESULTS

Thirty-nine completed studies were included. Despite some variability in studies narratively reviewed, in studies meta-analysed self-management interventions improved physical function in the short-term, post-treatment to 3 months (SMD 0.42, 95% CI 0.20, 0.64) and long-term, post 6 months (SMD 0.36, 95% CI 0.20, 0.53), compared to no treatment/usual care controls. Studies reporting on pain narratively had greater variability, however, those studies meta-analysed showed self-management interventions reduced pain in the short-term (SMD -0.49, 95% CI -0.70, -0.27) and long-term (SMD -0.38, 95% CI -0.58, -0.19) compared to no treatment/usual care. There were few differences in physical function and pain when self-management interventions were compared to active interventions. The quality of the evidence was rated as low.

CONCLUSION

Reviewed studies suggest self-management interventions can be effective in improving physical function and reducing pain in the short and long-term for CWP including fibromyalgia. However, the quality of evidence was low. Future research should address quality issues whilst making greater use of theory and patient involvement to understand reported variability.

Pain-Related Activity Management Patterns as Predictors of Treatment Outcomes in Patients with Fibromyalgia Syndrome

OBJECTIVES

This study sought to determine if pre- to post-treatment changes in pain-related activity patterns (i.e., overdoing, avoidance, and pacing) were associated with pre- to post-treatment changes in function (i.e., pain interference, psychological function, and physical function) in patients with fibromyalgia syndrome who participated in either an operant learning- or an energy conservation-based training in activity management.

METHODS

Sixty-nine patients with fibromyalgia syndrome participated in an activity management treatment (32 in an operant learning group and 37 in an energy conservation group). Outcomes were assessed at pre- and post-treatment, and patients provided demographic information and completed measures assessing pain intensity, pain interference, psychological function, physical function, and pain management activity patterns. Three linear hierarchical regression analyses predicting changes in pain outcomes from changes in pacing, overdoing, and avoidant activity patterns were performed.

RESULTS

Changes in pain-related activity patterns made significant contributions to the prediction of changes in patients' function. Specifically: (a) increases in overdoing predicted reductions in pain interference; (b) decreases in avoidance predicted improvements in psychological function; and (c) increases in pacing predicted improvements in physical function.

CONCLUSIONS

This study provides support for a role of activity management treatments in improved adjustment to chronic pain. Research is needed to replicate and extend these findings in order to build an empirical basis for developing more effective chronic pain treatments for facilitating improved physical and psychological function in individuals with chronic pain.

Clustering fibromyalgia patients: A combination of psychosocial and somatic factors leads to resilient coping in a subgroup of fibromyalgia patients

Background

Coping strategies and their efficacy vary greatly in patients suffering from fibromyalgia syndrome (FMS).

Objective

We aimed to identify somatic and psychosocial factors that might contribute to different coping strategies and resilience levels in FMS.

Subjects and methods

Standardized questionnaires were used to assess coping, pain, and psychological variables in a cohort of 156 FMS patients. Quantitative real-time polymerase chain reaction (qRT-PCR) determined gene expression of selected cytokines in white blood cells of 136 FMS patients and 25 healthy controls. Data of skin innervation, functional and structural sensory profiles of peripheral nociceptive nerve fibers of a previous study were included into the statistics. An exploratory factor analysis was used to define variance explaining factors, which were then included into cluster analysis.

Results

54.9% of the variance was explained by four factors which we termed (1) affective load, (2) coping, (3) pain, and (4) pro-inflammatory cytokines (p < 0.05). Considering differences in the emerged factors, coping strategies, cytokine profiles, and disability levels, 118 FMS patients could be categorized into four clusters which we named “maladaptive”, “adaptive”, “vulnerable”, and “resilient” (p < 0.05). The adaptive cluster had low scores in disability and in all symptom categories in contrast to the vulnerable cluster, which was characterized by high scores in catastrophizing and disability (p < 0.05). The resilient vs. the maladaptive cluster was characterized by better coping and a less pro-inflammatory cytokine pattern (p < 0.05).

Conclusion

Our data suggest that problem- and emotion-focused coping strategies and an anti-inflammatory cytokine pattern are associated with reduced disability and might promote resilience. Additional personal factors such as low anxiety scores, ability of acceptance, and persistence further favor a resilient phenotype. Individualized therapy should take these factors into account.

Perceived Stress and Inflammatory Arthritis: A Prospective Investigation in the Studies of the Etiologies of Rheumatoid Arthritis Cohort

OBJECTIVE

The aim of this study was to determine the association of perceived stress with incident inflammatory arthritis (IA) defined as having at least 1 joint consistent with rheumatoid arthritis (RA)-like synovitis based on examination.

METHODS

We conducted a prospective cohort study in the Studies of the Etiologies of Rheumatoid Arthritis cohort. Participants without IA were recruited if they were a first-degree relative of an RA proband or screened positive for anti-citrullinated protein antibody. Perceived stress was measured using the Perceived Stress Scale-14 (PSS-14), in which scores can range from 0 to 56, and a higher score indicates greater perceived stress. The total PSS-14 score, as well as 2 subscores indicative of perceived distress and self-efficacy, were averaged across all study visits until development of IA or the last follow-up. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) of IA associated with average PSS-14 scores were obtained using Cox proportional hazards models.

RESULTS

The mean total PSS-14 score was 20.4. We found that a 1-point increase in the perceived distress score was significantly associated with a 10-percent increase in the risk of IA (adjusted HR 1.10 [95% CI 1.02-1.19]). Total PSS-14 and self-efficacy were not associated with IA risk (adjusted HR 1.05 [95% CI 0.99-1.10] and 1.04 [95% CI 0.91-1.18], respectively).

CONCLUSION

An association between perceived distress and incident IA was observed in this at-risk cohort. Replication of this finding in other preclinical and at-risk RA populations is needed.

Evolving concepts in ventral hernia repair and physical therapy: prehabilitation, rehabilitation, and analogies to tendon reconstruction

PURPOSE

The abdominal wall and musculoskeletal tendons share many anatomic, physiologic, and functional characteristics. This review aims to highlight these similar characteristics and to present a rationale why the treatment principles of successful musculoskeletal tendon reconstruction, including principles of surgical technique and physical therapy, can be used in the treatment of complex abdominal wall reconstruction or ventral hernia repair.

METHODS

The MEDLINE/PubMed database was used to identify published literature relevant to the purpose of this review.

CONCLUSIONS

There are several anatomical and functional similarities between the linea alba and musculoskeletal tendons. Because of this reason, many of the surgical principles for musculoskeletal tendon repair and ventral hernia repair overlap. Distribution of tension is the main driving principle for both procedures. Suture material and configuration are chosen to maximize tension distribution among the tissue edges, as seen in the standard of care multistrand repairs for musculoskeletal tendons, as well as in the small bites for laparotomy technique described in the STITCH trial. Physical therapy is also one of the mainstays of tendon repair, but surprisingly, is not routine in ventral hernia repair. The evidence surrounding physical therapy prehabilitation and rehabilitation protocols in other disciplines is significant. This review challenges the fact that these protocols are not routinely implemented for ventral hernia repair, and presents the rationale and feasibility for the routine practice of physical therapy in ventral hernia repair.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012.

OBJECTIVES

To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU).

SEARCH METHODS

We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials.

SELECTION CRITERIA

RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end.

DATA COLLECTION AND ANALYSIS

Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment.

MAIN RESULTS

We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned.

AUTHORS' CONCLUSIONS

We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT.

Chronic Pain Self-Management Support With Pain Science Education and Exercise (COMMENCE) for People With Chronic Pain and Multiple Comorbidities: A Randomized Controlled Trial

OBJECTIVE

To investigate the effectiveness of chronic pain self-management support with pain science education and exercise (COMMENCE) on improving function, pain interference, work status, pain intensity, fatigue, psychological factors associated with pain, health care visits, satisfaction, and perceived change compared with usual care.

DESIGN

Parallel group randomized controlled trial with 1- and 12-week follow-ups.

SETTING

Community health center.

PARTICIPANTS

Adults (N=102) with chronic noncancer pain referred for self-management support. Eighty of 102 participants completed 12-week follow-up assessments. No participants withdrew with adverse events.

INTERVENTIONS

Participants were randomized to COMMENCE or usual care.

MAIN OUTCOME MEASURES

Primary: Function measured using the Short Musculoskeletal Function Assessment-Dysfunction Index. Secondary: Short Musculoskeletal Function Assessment-Bother Index, Patient Reported Outcomes Measurement Information System pain interference, work status, numeric pain, and fatigue rating scales, Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Pain Self-Efficacy Scale, Neurophysiology of Pain Questionnaire, number of health care visits, satisfaction, and global rating of change.

RESULTS

COMMENCE resulted in greater improvements in function (mean difference [MD] at 12-wk follow-up=-8.0; 95% CI, -14.7 to -1.3), bother with functional difficulties (MD, -12.0; 95% CI, -20.8 to -3.2), pain intensity (MD, -1.0; 95% CI, -2.1 to -0.1), catastrophizing (MD , -8.2; 95% CI, -14.5 to -2.0), self-efficacy (MD, 7.0; 95% CI, 0.8-13.2), knowledge (MD, 2.8; 95% CI, 1.6-3.9), satisfaction (MD, 1.2; 95% CI, 0.7-1.8), and perceived change (MD, 1.4; 95% CI, 0.8-2.1). There were no significant between-group differences in pain interference, work, fatigue, depressive symptoms, or health care visits.

CONCLUSION

COMMENCE is more effective than usual care at improving function, pain, catastrophic thinking, self-efficacy, pain knowledge, satisfaction, and perceived change but not pain interference, work status, fatigue, depressive symptoms, or health care visits.

Implementing guided ICBT for chronic pain and fatigue: A qualitative evaluation among therapists and managers

INTRODUCTION

Internet-based cognitive behavioural therapy (ICBT) for chronic pain and chronic fatigue syndrome (CFS) has a high potential to increase the number of patients who can receive an evidence based treatment aimed to reduce symptoms and/or disability and to lower burden on (mental) health care. However, implementing a new behaviour-change intervention, and especially an online intervention, has shown to be a challenge. This study aimed to identify factors influencing the implementation process of ICBT for chronic pain and CFS in mental health care.

METHODS

A qualitative study using semi-structured interviews with therapists and managers from twelve mental health care clinics was conducted. Questions and analysis were guided by the Consolidated Framework for Implementation Research (CFIR), covering five domains: (1) the implemented intervention, (2) individual characteristics of the users, (3) the inner setting of implementation, (4) the outer setting, and (5) the implementation process.

RESULTS

In all five domains important facilitators and barriers were found. Key themes were: (1) the quality of the content, its perceived effectiveness and usability, (2) the attitude, self-efficacy and ability to learn new skills among therapists, and motivation to start online treatment among patients, (3) internal communication within a team, existing workload, and top-down support from the management, (4) availability of reimbursement options and marketing strategies, and (5) involvement of all key stakeholders, steering towards independence of the implementation sites during the process and adequate training of therapists.

CONCLUSIONS

This study provides insight in the challenge of implementing ICBT for chronic pain and CFS in daily clinical practice. Several lessons can be learned from the interviews with therapists and managers which can also be more broadly applied to (ICBT) implementation projects in general. Development of practical tools to support the implementation process would be a valuable next step to overcome certain challenges at forehand and to properly prepare for those expected to come along.

Survey of activity pacing across healthcare professionals informs a new activity pacing framework for chronic pain/fatigue

INTRODUCTION

Activity pacing is considered a key component of rehabilitation programmes for chronic pain/fatigue. However, there are no widely used guidelines to standardize how pacing is delivered. This study aimed to undertake the first stage in developing a comprehensive evidence-based activity pacing framework.

METHODS

An online survey across pain/fatigue services in English National Health Service trusts explored healthcare professionals' opinions on the types/uses of pacing, aims, facets and perceived effects. Data were analysed using descriptive statistics for closed-ended questions and thematic analysis for open-ended questions. Purposeful recruitment with a snowball effect engaged 92 healthcare professionals (physiotherapists, occupational therapists, nurses, doctors and psychologists) to the study.

RESULTS

Pacing was highly utilized, with perceived long-term benefits for patients (n = 83, 90.2% healthcare professionals instructed pacing). The most endorsed aim of pacing was "achievement of meaningful activities" (24.5% of ranked votes). The least endorsed aim was "to conserve energy" (0.1% of ranked votes). The most frequently supported facet of pacing was "breaking down tasks" (n = 91, 98.9%). The least supported facet was "stopping activities when symptoms increase" (n = 6, 6.5%). Thematic analysis showed recurring themes that pacing involved flexibility and sense of choice.

CONCLUSIONS

Pacing is a multidimensional coping strategy and complex behaviour. The message is clear that pacing should enable increases in meaningful activities, as opposed to attempting to avoid symptoms. The survey findings have informed the development of an activity pacing framework to guide healthcare professionals on the multiple components of pacing. This will help to standardize and optimize treatments for chronic pain/fatigue and enable future investigations.

Group Psychotherapy With Fibromyalgia Patients: A Systematic Review

Objectives

This review aims to investigate the factors that play a role on the efficacy of group psychotherapy (GP) interventions for fibromyalgia syndrome (FMS).

Materials and methods

We employed a search using keywords group psychotherapy and fibromyalgia in the databases of Scopus, Web of Sciences, CINAHL, BMJ, MEDLINE, ScienceDirect and EBSCOhost.

Results

A total of 30 original studies were identified. These studies, which aimed to improve primary outcomes (POs-pain and fibromyalgia impact) and/or secondary outcomes (SOs-psychosocial), indicated that 15 were conducted in a multidisciplinary (MT) fashion, and the rest were unidimensional as they employed only GPs. Cognitive behavior therapy, which modifies dysfunctional thoughts and accompanying behaviors, was the most utilized psychological intervention. Overall, MTs were only slightly superior to GPs; however, improvements in POs were more frequent than SOs in MTs, and the vice versa in GPs.

Conclusion

Although studies varied in various methodological characteristics, the content of the interventions in MTs should be designed to cover the biopsychosocial nature of FMS.

The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: A systematic review and meta-analysis of randomized controlled trials

Study Design: Systematic Review with meta-analysis.Background: Rehabilitation providers have begun to incorporate pain education into their treatment protocols to influence the patient's experience and knowledge to improve their condition. The purpose of this systematic review is to determine if the addition of pain education strategies to physical therapy treatments is beneficial in reducing pain intensity and disability for those with chronic musculoskeletal pain.Methods: A systematic database search was conducted for randomized control trials that investigated the concurrent use of pain education and physical therapy. Standardized methods for article identification, inclusion, and quality appraisal was utilized. Where possible, studies were pooled for meta-analysis, with pain and disability as the primary outcomes.Results: Fourteen articles were included in this review, of which all fourteen were rated as high quality using the PEDro scale of quality assessment. Meta-analyses were conducted on pain and disability constructs at short term (< 12 weeks) and long-term (≥ 12 weeks) for the studies that allowed for quantitative pooling of effect sizes. Thirteen out of the fourteen included studies demonstrated a decrease in pain and disability with the use of combined interventions. There was a large effect on short-term pain (SMD 0.837), long-term pain (SMD 0.964), and long-term disability (SMD 1.374). A moderate effect on with short-term disability (SMD 0.791).Conclusion: The results of this systematic review support the conclusion that utilizing pain education strategies in conjunction with interventions provided by physical therapists demonstrates a moderate to large effect sizes on pain and disability constructs but lack pooled statistical significance.

Mixed exercise training for adults with fibromyalgia

BACKGROUND

Exercise training is commonly recommended for individuals with fibromyalgia. This review is one of a series of reviews about exercise training for fibromyalgia that will replace the review titled "Exercise for treating fibromyalgia syndrome", which was first published in 2002.

OBJECTIVES

To evaluate the benefits and harms of mixed exercise training protocols that include two or more types of exercise (aerobic, resistance, flexibility) for adults with fibromyalgia against control (treatment as usual, wait list control), non exercise (e.g. biofeedback), or other exercise (e.g. mixed versus flexibility) interventions.Specific comparisons involving mixed exercise versus other exercises (e.g. resistance, aquatic, aerobic, flexibility, and whole body vibration exercises) were not assessed.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Thesis and Dissertations Abstracts, the Allied and Complementary Medicine Database (AMED), the Physiotherapy Evidence Databese (PEDro), Current Controlled Trials (to 2013), WHO ICTRP, and ClinicalTrials.gov up to December 2017, unrestricted by language, to identify all potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults with a diagnosis of fibromyalgia that compared mixed exercise interventions with other or no exercise interventions. Major outcomes were health-related quality of life (HRQL), pain, stiffness, fatigue, physical function, withdrawals, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias and the quality of evidence for major outcomes using the GRADE approach.

MAIN RESULTS

We included 29 RCTs (2088 participants; 98% female; average age 51 years) that compared mixed exercise interventions (including at least two of the following: aerobic or cardiorespiratory, resistance or muscle strengthening exercise, and flexibility exercise) versus control (e.g. wait list), non-exercise (e.g. biofeedback), and other exercise interventions. Design flaws across studies led to selection, performance, detection, and selective reporting biases. We prioritised the findings of mixed exercise compared to control and present them fully here.Twenty-one trials (1253 participants) provided moderate-quality evidence for all major outcomes but stiffness (low quality). With the exception of withdrawals and adverse events, major outcome measures were self-reported and expressed on a 0 to 100 scale (lower values are best, negative mean differences (MDs) indicate improvement; we used a clinically important difference between groups of 15% relative difference). Results for mixed exercise versus control show that mean HRQL was 56 and 49 in the control and exercise groups, respectively (13 studies; 610 participants) with absolute improvement of 7% (3% better to 11% better) and relative improvement of 12% (6% better to 18% better). Mean pain was 58.6 and 53 in the control and exercise groups, respectively (15 studies; 832 participants) with absolute improvement of 5% (1% better to 9% better) and relative improvement of 9% (3% better to 15% better). Mean fatigue was 72 and 59 points in the control and exercise groups, respectively (1 study; 493 participants) with absolute improvement of 13% (8% better to 18% better) and relative improvement of 18% (11% better to 24% better). Mean stiffness was 68 and 61 in the control and exercise groups, respectively (5 studies; 261 participants) with absolute improvement of 7% (1% better to 12% better) and relative improvement of 9% (1% better to 17% better). Mean physical function was 49 and 38 in the control and exercise groups, respectively (9 studies; 477 participants) with absolute improvement of 11% (7% better to 15% better) and relative improvement of 22% (14% better to 30% better). Pooled analysis resulted in a moderate-quality risk ratio for all-cause withdrawals with similar rates across groups (11 per 100 and 12 per 100 in the control and intervention groups, respectively) (19 studies; 1065 participants; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.69 to 1.51) with an absolute change of 1% (3% fewer to 5% more) and a relative change of 11% (28% fewer to 47% more). Across all 21 studies, no injuries or other adverse events were reported; however some participants experienced increased fibromyalgia symptoms (pain, soreness, or tiredness) during or after exercise. However due to low event rates, we are uncertain of the precise risks with exercise. Mixed exercise may improve HRQL and physical function and may decrease pain and fatigue; all-cause withdrawal was similar across groups, and mixed exercises may slightly reduce stiffness. For fatigue, physical function, HRQL, and stiffness, we cannot rule in or out a clinically relevant change, as the confidence intervals include both clinically important and unimportant effects.We found very low-quality evidence on long-term effects. In eight trials, HRQL, fatigue, and physical function improvement persisted at 6 to 52 or more weeks post intervention but improvements in stiffness and pain did not persist. Withdrawals and adverse events were not measured.It is uncertain whether mixed versus other non-exercise or other exercise interventions improve HRQL and physical function or decrease symptoms because the quality of evidence was very low. The interventions were heterogeneous, and results were often based on small single studies. Adverse events with these interventions were not measured, and thus uncertainty surrounds the risk of adverse events.

AUTHORS' CONCLUSIONS

Compared to control, moderate-quality evidence indicates that mixed exercise probably improves HRQL, physical function, and fatigue, but this improvement may be small and clinically unimportant for some participants; physical function shows improvement in all participants. Withdrawal was similar across groups. Low-quality evidence suggests that mixed exercise may slightly improve stiffness. Very low-quality evidence indicates that we are 'uncertain' whether the long-term effects of mixed exercise are maintained for all outcomes; all-cause withdrawals and adverse events were not measured. Compared to other exercise or non-exercise interventions, we are uncertain about the effects of mixed exercise because we found only very low-quality evidence obtained from small, very heterogeneous trials. Although mixed exercise appears to be well tolerated (similar withdrawal rates across groups), evidence on adverse events is scarce, so we are uncertain about its safety. We downgraded the evidence from these trials due to imprecision (small trials), selection bias (e.g. allocation), blinding of participants and care providers or outcome assessors, and selective reporting.

Operant Learning Versus Energy Conservation Activity Pacing Treatments in a Sample of Patients With Fibromyalgia Syndrome: A Pilot Randomized Controlled Trial

This study's aim was to assess the efficacy of 2 forms of activity pacing in patients with fibromyalgia syndrome (FMS). Treatment-related changes in activity management patterns were also examined. Patients with FMS (n = 178) were randomly assigned to an operant learning (OL; delayed [n = 36] or immediate [n = 54] groups) or an energy conservation (EC; delayed [n = 35] or immediate [n = 53] groups) treatment condition. Of these, 32 OL and 37 EC patients completed treatment. Forty-three patients were allocated to the delayed treatment condition (control group). Repeated measures analyses of variance were used to examine the effects of OL and EC treatments on primary (average pain and usual fatigue), secondary (pain and fatigue interference, physical and psychological function, sleep quality, depressive symptoms, and anxiety symptoms), and tertiary (pain-related activity patterns) outcomes. Neither treatment was effective in reducing average pain or usual fatigue symptoms. Relative to EC, OL patients showed greater improvements in depressive symptoms, whereas nonsignificant trends (P values ranging between .05 and .06) were observed for pain interference, fatigue interference, and psychological function. Both treatments were associated with improvements in sleep quality and physical function, increases in pacing, and decreases in overdoing activity patterns. Reductions in activity avoidance were only found in OL. These findings suggest that OL may be more beneficial than EC and that it could potentially be viewed as an effective stand-alone activity pacing treatment for patients with FMS. Research to determine the extent to which these preliminary findings replicate is warranted. PERSPECTIVE: This article examines the efficacy of 2 forms of activity pacing in patients with fibromyalgia syndrome. The results suggest the possibility that operant learning may be more beneficial than energy conservation and could potentially be viewed as an effective stand-alone activity pacing treatment for patients with fibromyalgia syndrome.

The role of nonpharmacologic therapies in management of chronic pelvic pain: what to do when surgery fails

PURPOSE OF REVIEW

To provide an update on nonsurgical and nonpharmacologic strategies for the management of chronic pelvic pain (CPP).

RECENT FINDINGS

Effective treatment of patients with CPP requires a multifaceted approach, with thoughtful consideration of surgical, pharmacologic, and nonpharmacologic strategies. Evidence for physical therapy and trigger point injections for treatment of myofascial components of CPP is increasing. Neuromodulation techniques, such as percutaneous tibial nerve stimulation and transcutaneous electrical stimulation, have limited but favorable preliminary data in patients with CPP. Behavioral strategies, such as exercise, cognitive behavioral therapy, and mindfulness, have demonstrated significant improvements in pain, function and quality of life in patients with a variety of chronic pain conditions and are promising avenues for future research in CPP.

SUMMARY

Nonpharmacologic therapies are important adjuncts to surgical and pharmacologic treatment for CPP and should be considered integral to a comprehensive treatment approach.

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.

Activity Pacing is Associated With Better and Worse Symptoms for Patients With Long-term Conditions

BACKGROUND

Activity pacing has been associated with both improved and worsened symptoms, and its role in reducing disability among patients with long-term conditions has been questioned. However, existing studies have measured pacing according to unidimensional subscales, and therefore the empirical evidence for pacing as a multifaceted construct remains unclear. We have developed a 26-item Activity Pacing Questionnaire (APQ-26) for chronic pain/fatigue containing 5 themes of pacing: activity adjustment, activity consistency, activity progression, activity planning, and activity acceptance.

OBJECTIVE

To assess the associations between the 5 APQ-26 pacing themes and symptoms of pain, physical fatigue, depression, avoidance, and physical function.

METHODS

Cross-sectional questionnaire study design. Data analyzed using multiple regression.

PARTICIPANTS

A total of 257 adult patients with diagnoses of chronic low back pain, chronic widespread pain, fibromyalgia, and chronic fatigue syndrome/myalgic encephalomyelitis.

RESULTS

Hierarchical multiple regression showed that activity adjustment was significantly associated with increased physical fatigue, depression, and avoidance, but decreased physical function (all Ps≤0.030). Activity consistency was associated with decreased pain, physical fatigue, depression, and avoidance, but increased physical function (all Ps≤0.003). Activity planning was associated with reduced physical fatigue (Ps=0.025) and activity acceptance was associated with increased avoidance (Ps=0.036).

CONCLUSIONS

Some APQ-26 pacing themes were associated with worse symptoms and others with symptom improvement. Specifically, pacing themes involving adjusting/reducing activities were associated with worse symptoms, whereas pacing themes involving undertaking consistent activities were associated with improved symptoms. Future study will explore the causality of these associations to add clarification regarding the effects of pacing on patients' symptoms.

Adaptation profiles comprising objective and subjective measures in fibromyalgia: the al-Ándalus project

Objectives

The aim of this study was to identify subgroups in terms of adaptation to FM and to test differences in FM severity between these subgroups.

Methods

The al-Ándalus project made it possible to perform a comprehensive population-based cross-sectional study in 486 FM patients including multiple assessments of modifiable (could be targeted in therapy) resilience and vulnerability factors, measured by objective and subjective assessments, related to psychological and physical function. FM severity was assessed by means of FM impact (total score of the Revised Fibromyalgia Impact Questionnaire) and distress (Polysymptomatic Distress Scale of the modified 2011 preliminary criteria for FM). Exploratory factor analysis, cluster analysis and analysis of variance were conducted.

Results

Factor analysis yielded eight factors: three included objective measures (declarative memory, active lifestyle and objective physical fitness) and five included subjective measures (fatigue, psychological distress, catastrophizing, resilience and subjective physical fitness). Cluster analysis based on these eight factors identified five profiles: Adapted (16%), Fit (18%), Poor performer (20%), Positive (20%) and Maladapted (26%). Most profile comparisons revealed different levels of FM severity varying from Adapted (the most favourable profile) to Maladapted (the most unfavourable profile) with Fit, Poor performer and Positive obtaining intermediate positions.

Conclusions

Heterogeneity of FM was shown by five clinically meaningful profiles of modifiable factors that were associated with FM severity. It is of clinical interest to examine whether these profiles are associated with FM prognosis and the effectiveness of interventions, which would enhance the development of customized interventions based on adaptation profiles in FM.

Physical activity and autoimmune diseases: Get moving and manage the disease

Physical activity, by definition, is any skeletal muscle body movement that results in energy expenditure. In the last few decades, a plethora of scientific evidences have accumulated and confirmed the beneficial role of physical activity as a modifiable risk factor for a wide variety of chronic diseases including cardiovascular diseases (CVDs), diabetes mellitus and cancer, among others. Autoimmune diseases are a heterogeneous group of chronic diseases, which occur secondary to loss of self-antigen tolerance. With the advent of biological therapies, better outcomes have recently been noted in the management of autoimmune diseases. Nonetheless, recent research highlights the salient role of modifiable behaviors such as physical inactivity on various aspects of the immune system and autoimmune diseases. Physical activity leads to a significant elevation in T-regulatory cells, decreased immunoglobulin secretion and produces a shift in the Th1/Th2 balance to a decreased Th1 cell production. Moreover, physical activity has been proven to promote the release of IL-6 from muscles. IL-6 released from muscles functions as a myokine and has been shown to induce an anti-inflammatory response through IL-10 secretion and IL-1β inhibition. Physical activity has been shown to be safe in most of autoimmune diseases including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), multiple sclerosis (MS), inflammatory bowel diseases (IBD), as well as others. Additionally, the incidence of RA, MS, IBD and psoriasis has been found to be higher in patients less engaged in physical activity. As a general trend, patients with autoimmune diseases tend to be less physically active as compared to the general population. Physically active RA patients were found to have a milder disease course, better cardiovascular disease (CVD) profile, and improved joint mobility. Physical activity decreases fatigue, enhances mood, cognitive abilities and mobility in patients with MS. In SLE patients, enhanced quality of life and better CVD profile were documented in more physically active patients. Physically active patients with type 1 diabetes mellitus have a decreased risk of autonomic neuropathy and CVD. Both fibromyalgia and systemic sclerosis patients report decreased disease severity, pain, as well as better quality of life with more physical activity. Further, SSc patients improve their grip strength, finger stretching and mouth opening with increased level of exercise. The purpose of this paper is to review the clinical evidence regarding the safety, barriers to engagement, and impact of physical activity on autoimmune diseases.

Whole body vibration exercise training for fibromyalgia

BACKGROUND

Exercise training is commonly recommended for adults with fibromyalgia. We defined whole body vibration (WBV) exercise as use of a vertical or rotary oscillating platform as an exercise stimulus while the individual engages in sustained static positioning or dynamic movements. The individual stands on the platform, and oscillations result in vibrations transmitted to the subject through the legs. This review is one of a series of reviews that replaces the first review published in 2002.

OBJECTIVES

To evaluate benefits and harms of WBV exercise training in adults with fibromyalgia.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, CINAHL, PEDro, Thesis and Dissertation Abstracts, AMED, WHO ICTRP, and ClinicalTrials.gov up to December 2016, unrestricted by language, to identify potentially relevant trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in adults with the diagnosis of fibromyalgia based on published criteria including a WBV intervention versus control or another intervention. Major outcomes were health-related quality of life (HRQL), pain intensity, stiffness, fatigue, physical function, withdrawals, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, performed risk of bias assessments, and assessed the quality of evidence for major outcomes using the GRADE approach. We used a 15% threshold for calculation of clinically relevant differences.

MAIN RESULTS

We included four studies involving 150 middle-aged female participants from one country. Two studies had two treatment arms (71 participants) that compared WBV plus mixed exercise plus relaxation versus mixed exercise plus relaxation and placebo WBV versus control, and WBV plus mixed exercise versus mixed exercise and control; two studies had three treatment arms (79 participants) that compared WBV plus mixed exercise versus control and mixed relaxation placebo WBV. We judged the overall risk of bias as low for selection (random sequence generation), detection (objectively measured outcomes), attrition, and other biases; as unclear for selection bias (allocation concealment); and as high for performance, detection (self-report outcomes), and selective reporting biases.The WBV versus control comparison reported on three major outcomes assessed at 12 weeks post intervention based on the Fibromyalgia Impact Questionnaire (FIQ) (0 to 100 scale, lower score is better). Results for HRQL in the control group at end of treatment (59.13) showed a mean difference (MD) of -3.73 (95% confidence interval [CI] -10.81 to 3.35) for absolute HRQL, or improvement of 4% (11% better to 3% worse) and relative improvement of 6.7% (19.6% better to 6.1% worse). Results for withdrawals indicate that 14 per 100 and 10 per 100 in the intervention and control groups, respectively, withdrew from the intervention (RR 1.43, 95% CI 0.27 to 7.67; absolute change 4%, 95% CI 16% fewer to 24% more; relative change 43% more, 95% CI 73% fewer to 667% more). The only adverse event reported was acute pain in the legs, for which one participant dropped out of the program. We judged the quality of evidence for all outcomes as very low. This study did not measure pain intensity, fatigue, stiffness, or physical function. No outcomes in this comparison met the 15% threshold for clinical relevance.The WBV plus mixed exercise (aerobic, strength, flexibility, and relaxation) versus control study (N = 21) evaluated symptoms at six weeks post intervention using the FIQ. Results for HRQL at end of treatment (59.64) showed an MD of -16.02 (95% CI -31.57 to -0.47) for absolute HRQL, with improvement of 16% (0.5% to 32%) and relative change in HRQL of 24% (0.7% to 47%). Data showed a pain intensity MD of -28.22 (95% CI -43.26 to -13.18) for an absolute difference of 28% (13% to 43%) and a relative change of 39% improvement (18% to 60%); as well as a fatigue MD of -33 (95% CI -49 to -16) for an absolute difference of 33% (16% to 49%) and relative difference of 47% (95% CI 23% to 60%); and a stiffness MD of -26.27 (95% CI -42.96 to -9.58) for an absolute difference of 26% (10% to 43%) and a relative difference of 36.5% (23% to 60%). All-cause withdrawals occurred in 8 per 100 and 33 per 100 withdrawals in the intervention and control groups, respectively (two studies, N = 46; RR 0.25, 95% CI 0.06 to 1.12) for an absolute risk difference of 24% (3% to 51%). One participant exhibited a mild anxiety attack at the first session of WBV. No studies in this comparison reported on physical function. Several outcomes (based on the findings of one study) in this comparison met the 15% threshold for clinical relevance: HRQL, pain intensity, fatigue, and stiffness, which improved by 16%, 39%, 46%, and 36%, respectively. We found evidence of very low quality for all outcomes.The WBV plus mixed exercise versus other exercise provided very low quality evidence for all outcomes. Investigators evaluated outcomes on a 0 to 100 scale (lower score is better) for pain intensity (one study, N = 23; MD -16.36, 95% CI -29.49 to -3.23), HRQL (two studies, N = 49; MD -6.67, 95% CI -14.65 to 1.31), fatigue (one study, N = 23; MD -14.41, 95% CI -29.47 to 0.65), stiffness (one study, N = 23; MD -12.72, 95% CI -26.90 to 1.46), and all-cause withdrawal (three studies, N = 77; RR 0.72, 95% CI -0.17 to 3.11). Adverse events reported for the three studies included one anxiety attack at the first session of WBV and one dropout from the comparison group ("other exercise group") due to an injury that was not related to the program. No studies reported on physical function.

AUTHORS' CONCLUSIONS

Whether WBV or WBV in addition to mixed exercise is superior to control or another intervention for women with fibromyalgia remains uncertain. The quality of evidence is very low owing to imprecision (few study participants and wide confidence intervals) and issues related to risk of bias. These trials did not measure major outcomes such as pain intensity, stiffness, fatigue, and physical function. Overall, studies were few and were very small, which prevented meaningful estimates of harms and definitive conclusions about WBV safety.

Unravelling Fibromyalgia-Steps Toward Individualized Management

The heterogeneity of the clinical presentation and the pathophysiologic mechanisms associated with fibromyalgia (FM), and the modest results on average for any therapy, call for a more individualized management strategy. Individualized treatment can be on the basis of subgrouping of patients according to associated conditions (mental health problems, chronic overlapping pain conditions, other somatic diseases) or on disease severity. Categorizing FM as mild, moderate, or severe can be on the basis of clinical assessment (eg, degree of daily functioning) or on questionnaires. Shared decision-making regarding treatment options can be directed according to patient preferences, comorbidities, and availability in various health care settings. The European League Against Rheumatism guidelines recommend a tailored approach directed by FM key symptoms (pain, sleep disorders, fatigue, depression, disability), whereas the German guidelines recommend management tailored to disease severity, with mild disease not requiring any specific treatment, and more severe disease requiring multicomponent therapy (combination of drug treatment with aerobic exercise and psychological treatments). When indicated, treatments should follow a stepwise approach beginning with easily available therapies such as aerobic exercise and amitriptyline. Successful application of a tailored treatment approach that is informed by individual patient characteristics should improve outcome of FM.

PERSPECTIVE

This article presents suggestions for an individualized treatment strategy for FM patients on the basis of subgroups and disease severity. Categorizing FM as mild, moderate, or severe can be on the basis of clinical assessment (eg, degree of daily functioning) or questionnaires. Subgroups can be defined according to mental health and somatic comorbidities.

Tailored Therapist-Guided Internet-Based Cognitive Behavioral Treatment for Psoriasis: A Randomized Controlled Trial

OBJECTIVE

Patients with somatic conditions, such as psoriasis, frequently suffer from high burden of their disease in daily life and might benefit from internet-based cognitive behavioral therapy (ICBT) tailored to their adjustment problems. The aim of this multicenter randomized controlled trial was to examine the effects of therapist-guided, individually tailored ICBT in a clinical sample of patients with psoriasis.

METHODS

A total of 131 patients with psoriasis, who were screened for a psychological risk profile, were randomized to either care as usual (CAU, n = 66) or ICBT in addition to CAU (n = 65). Participants filled out standardized self-report questionnaires assessing physical and psychological functioning and impact on daily activities at baseline, posttreatment assessment, and 6-month follow-up.

RESULTS

In covariate-controlled linear mixed-model analyses, significantly larger improvements in ICBT compared to CAU were found in the primary outcomes physical functioning (p = 0.03, d = 0.36) and impact on daily activities (p = 0.04, d = 0.35), but not in psychological functioning (p = 0.32), up to 6 months after treatment compared to baseline. In explorative analyses, the working alliance measured at the beginning of ICBT treatment predicted improved physical (p = 0.02) and psychological (p < 0.001) outcomes.

CONCLUSIONS

Results underline the promise of therapist-guided, individually tailored ICBT to improve physical functioning and reduce the impact of psoriasis on daily activities in patients with a psychological risk profile. Establishing a good therapeutic relationship early on may be an important factor that influences treatment outcomes in personalized ICBT interventions. Further research is needed to evaluate ICBT effectiveness in additional samples and to explore its underlying mechanisms.

Aerobic exercise training for adults with fibromyalgia

BACKGROUND

Exercise training is commonly recommended for individuals with fibromyalgia. This review is one of a series of reviews about exercise training for people with fibromyalgia that will replace the "Exercise for treating fibromyalgia syndrome" review first published in 2002.

OBJECTIVES

• To evaluate the benefits and harms of aerobic exercise training for adults with fibromyalgia• To assess the following specific comparisons ० Aerobic versus control conditions (eg, treatment as usual, wait list control, physical activity as usual) ० Aerobic versus aerobic interventions (eg, running vs brisk walking) ० Aerobic versus non-exercise interventions (eg, medications, education) We did not assess specific comparisons involving aerobic exercise versus other exercise interventions (eg, resistance exercise, aquatic exercise, flexibility exercise, mixed exercise). Other systematic reviews have examined or will examine these comparisons (Bidonde 2014; Busch 2013).

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Physiotherapy Evidence Database (PEDro), Thesis and Dissertation Abstracts, the Allied and Complementary Medicine Database (AMED), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and the ClinicalTrials.gov registry up to June 2016, unrestricted by language, and we reviewed the reference lists of retrieved trials to identify potentially relevant trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in adults with a diagnosis of fibromyalgia that compared aerobic training interventions (dynamic physical activity that increases breathing and heart rate to submaximal levels for a prolonged period) versus no exercise or another intervention. Major outcomes were health-related quality of life (HRQL), pain intensity, stiffness, fatigue, physical function, withdrawals, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, performed a risk of bias assessment, and assessed the quality of the body of evidence for major outcomes using the GRADE approach. We used a 15% threshold for calculation of clinically relevant differences between groups.

MAIN RESULTS

We included 13 RCTs (839 people). Studies were at risk of selection, performance, and detection bias (owing to lack of blinding for self-reported outcomes) and had low risk of attrition and reporting bias. We prioritized the findings when aerobic exercise was compared with no exercise control and present them fully here.Eight trials (with 456 participants) provided low-quality evidence for pain intensity, fatigue, stiffness, and physical function; and moderate-quality evidence for withdrawals and HRQL at completion of the intervention (6 to 24 weeks). With the exception of withdrawals and adverse events, major outcome measures were self-reported and were expressed on a 0 to 100 scale (lower values are best, negative mean differences (MDs)/standardized mean differences (SMDs) indicate improvement). Effects for aerobic exercise versus control were as follows: HRQL: mean 56.08; five studies; N = 372; MD -7.89, 95% CI -13.23 to -2.55; absolute improvement of 8% (3% to 13%) and relative improvement of 15% (5% to 24%); pain intensity: mean 65.31; six studies; N = 351; MD -11.06, 95% CI -18.34 to -3.77; absolute improvement of 11% (95% CI 4% to 18%) and relative improvement of 18% (7% to 30%); stiffness: mean 69; one study; N = 143; MD -7.96, 95% CI -14.95 to -0.97; absolute difference in improvement of 8% (1% to 15%) and relative change in improvement of 11.4% (21.4% to 1.4%); physical function: mean 38.32; three studies; N = 246; MD -10.16, 95% CI -15.39 to -4.94; absolute change in improvement of 10% (15% to 5%) and relative change in improvement of 21.9% (33% to 11%); and fatigue: mean 68; three studies; N = 286; MD -6.48, 95% CI -14.33 to 1.38; absolute change in improvement of 6% (12% improvement to 0.3% worse) and relative change in improvement of 8% (16% improvement to 0.4% worse). Pooled analysis resulted in a risk ratio (RR) of moderate quality for withdrawals (17 per 100 and 20 per 100 in control and intervention groups, respectively; eight studies; N = 456; RR 1.25, 95%CI 0.89 to 1.77; absolute change of 5% more withdrawals with exercise (3% fewer to 12% more).Three trials provided low-quality evidence on long-term effects (24 to 208 weeks post intervention) and reported that benefits for pain and function persisted but did not for HRQL or fatigue. Withdrawals were similar, and investigators did not assess stiffness and adverse events.We are uncertain about the effects of one aerobic intervention versus another, as the evidence was of low to very low quality and was derived from single trials only, precluding meta-analyses. Similarly, we are uncertain of the effects of aerobic exercise over active controls (ie, education, three studies; stress management training, one study; medication, one study) owing to evidence of low to very low quality provided by single trials. Most studies did not measure adverse events; thus we are uncertain about the risk of adverse events associated with aerobic exercise.

AUTHORS' CONCLUSIONS

When compared with control, moderate-quality evidence indicates that aerobic exercise probably improves HRQL and all-cause withdrawal, and low-quality evidence suggests that aerobic exercise may slightly decrease pain intensity, may slightly improve physical function, and may lead to little difference in fatigue and stiffness. Three of the reported outcomes reached clinical significance (HRQL, physical function, and pain). Long-term effects of aerobic exercise may include little or no difference in pain, physical function, and all-cause withdrawal, and we are uncertain about long-term effects on remaining outcomes. We downgraded the evidence owing to the small number of included trials and participants across trials, and because of issues related to unclear and high risks of bias (performance, selection, and detection biases). Aerobic exercise appears to be well tolerated (similar withdrawal rates across groups), although evidence on adverse events is scarce, so we are uncertain about its safety.

Challenges of implementing fibromyalgia treatment guidelines in current clinical practice

The current diagnostic and treatment pathway for patients with fibromyalgia (FM) is lengthy, complex, and characterized by multiple physician visits with an average 2-year wait until diagnosis. It is clear that effective identification and appropriate treatment of FM remain a challenge in current clinical practice. Ideally, FM management involves a multidisciplinary approach with the preferable patient pathway originating in primary care but supported by a range of health care providers, including referral to specialist care when necessary. After the publication of individual clinical studies, high-quality reviews, and meta-analyses, recently published FM treatment guidelines have transitioned from an expert consensus to an evidence-based approach. Evidence-based guidelines provide a framework for ensuring early diagnosis and timely adoption of appropriate treatment. However, for successful outcomes, FM treatments must adopt a more holistic approach, which addresses more than just pain. Impact on the associated symptoms of fatigue and cognitive problems, sleep and mood disturbances, and lowered functional status are also important in judging the success of FM therapy. Recently published guidelines recommend the adoption of a symptom-based approach to guide pharmacologic treatment. Emerging treatment options for FM may be best differentiated on the basis of their effect on comorbid symptoms that are often associated with pain (e.g. sleep disturbance, mood, fatigue). The current review discusses the most recently published Canadian guidelines and the implications of the recent European League Against Rheumatism (EULAR) recommendations, with a focus on the challenges of implementing these guidelines in current clinical practice.

The placebo effect and its determinants in fibromyalgia: meta-analysis of randomised controlled trials

The aims of this study were to determine whether placebo treatment in randomised controlled trials (RCTs) is effective for fibromyalgia and to identify possible determinants of the magnitude of any such placebo effect. A systematic literature search was undertaken for RCTs in people with fibromyalgia that included a placebo and/or a no-treatment (observation only or waiting list) control group. Placebo effect size (ES) for pain and other outcomes was measured as the improvement of each outcome from baseline divided by the standard deviation of the change from baseline. This effect was compared with changes in the no-treatment control groups. Meta-analysis was undertaken to combine data from different studies. Subgroup analysis was conducted to identify possible determinants of the placebo ES. A total of 3912 studies were identified from the literature search. After scrutiny, 229 trials met the inclusion criteria. Participants who received placebo in the RCTs experienced significantly better improvements in pain, fatigue, sleep quality, physical function, and other main outcomes than those receiving no treatment. The ES of placebo for pain relief was clinically moderate (0.53, 95%CI 0.48 to 0.57). The ES increased with increasing strength of the active treatment, increasing participant age and higher baseline pain severity, but decreased in RCTS with more women and with longer duration of fibromyalgia. In addition, placebo treatment in RCTs is effective in fibromyalgia. A number of factors (expected strength of treatment, age, gender, disease duration) appear to influence the magnitude of the placebo effect in this condition.

A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo

Background

Some evidence showed that multidisciplinary rehabilitation in Western countries is effective for treating war-related trauma, but it remains unclear whether this approach is applicable to civilians living in resource-poor countries affected by war. In 2012–14, Danish Institute against Torture (DIGNITY) conducted a randomized controlled trial (RCT), in partnership with Kosova Rehabilitation Centre for Torture Victims (KRCT), to examine the effects of multidisciplinary intervention among victims of torture and war in Kosovo.

Methods

A single-center, randomized, parallel-arm, single-masked, waiting-list controlled trial was implemented in northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group, which received integrated treatments plus a once-daily multivitamin, or the waiting list group, which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-min sessions of cognitive behavioral therapy (CBT), based on an adapted prolonged exposure therapy manual, an individual 20-min breathing exercise with an emWave biofeedback device, and 90-min group physiotherapy. The waiting list group also received the same treatment after the intervention group had completed their sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Outcomes measures consisted of 4 subtypes: mental, emotional, physical health, functioning and social outcomes, i.e. PTSD, depression, anxiety, chronic pain, anger and hatred expression, body mass index, handgrip strength, standing balance, income, employment rate and disability score.

Results

Over 1/3 of PTSD cases were successfully treated. Inconsistent patterns with mental health and chronic pain outcomes were observed while there was a definite impact of intervention on functioning and social outcomes, i.e. the employment rate, which increased nearly 15 %, and the monthly wage, which rose 45–137 %. There was also a noticeable improvement in handgrip strength and disability score; the feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance.

Conclusions

The impact of bio-psycho-social intervention is likely sensitive to the context of post-war economy in Kosovo and the treatment goals. The potential for improving the emotional well-being and employment outcome in victims was demonstrated. A larger scale RCT in a similar setting is needed, with close monitoring of treatment integrity and data reliability.

Trial registration

Clinicaltrials.gov (NCT01696578).

The role of psychological factors in inflammatory rheumatic diseases: From burden to tailored treatment

Inflammatory rheumatic diseases have a long-lasting effect on patients' physical and psychological functioning, for instance, due to disabling symptoms and unpredictable disease course. Consequently, many patients show adjustment problems such as depressed mood, which in turn can negatively influence their disease outcome. Specific biopsychosocial factors have shown to affect this outcome. For example, daily stress, cognitive-behavioral risk factors such as pain catastrophizing and avoidance, and resilience factors such as optimism and social support influence the quality of life, physical symptoms of pain and fatigue, and inflammatory markers. Psychological interventions tackling these factors can have beneficial effects on physical and psychological functioning. Recent advances in screening for patients at risk, tailored treatment, and eHealth further broaden the efficiency and scope of these interventions while simultaneously optimizing patient empowerment. This chapter describes the biopsychosocial risk and resilience factors related to disease outcome and the possible benefits of psychological treatment strategies in inflammatory rheumatic diseases.