Multidisciplinary approach to fibromyalgia. A pilot study

Breast Implant Illness Through a Psychiatric Lens

Since their introduction in the 1960's, the safety of silicone breast implants has remained contentious due to concerns regarding carcinogenicity as well as a growing array of adverse psychiatric symptoms, which have now been termed 'Breast Implant Illness.' This article aims to explore the merits of a psychiatric approach to treating Breast Implant Illness by outlining how it is defined by psychiatric symptoms and categorized alongside other psychiatric illnesses. Furthermore, it is unclear whether the pathology of Breast Implant Illness is purely medical or psychiatric. However, the efficacy of the medical approach to treatment through a process called explantation, which involves removal of the implant and surrounding scar tissue, or capsule, is not strongly supported by existing data. A psychiatric approach to treatment, in conjunction with explanation, thus holds potential in remedying the novel and poorly understood Breast Implant Illness.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Exploratory Investigation of a Brief Cognitive Behavioral Intervention and Transcranial Direct Current Stimulation on Odor Sensitivity

OBJECTIVE

Enhanced odor sensitivity is a phenomenon that potentially underlies conditions such as multiple chemical sensitivity (MCS). Currently, there are no treatments that have been shown to effectively decrease odor sensitivity. Given similarities of odor hypersensitivity/MCS to pain sensitization disorders such as fibromyalgia, there may be a potential for interventions that improve pain tolerance to modulate odor sensitivity.

METHODS

This exploratory study randomized 72 healthy community adult volunteers to receive one of six treatments in between two assessments of thermal pain tolerance and odor threshold. Participants were randomized to receive either cathodal, anodal, or sham transcranial direct current stimulation (tDCS) aimed at dorsolateral prefrontal cortex. In addition, participants were provided a brief cognitive behavioral intervention (CBI) for pain consisting of task framing, cognitive restructuring, and distraction technique training, or a control intervention consisting of information about pain.

RESULTS

Persons who received a brief CBI showed significantly increased odor thresholds (reduced sensitivity) during intervention (F (1,62) = 7.29, p = .009, ηp = .11), whereas the control intervention was not associated with altered odor thresholds. Moreover, in those who received brief CBI, more severe anxiety associated with larger reductions in odor sensitivity (ρ = .364, p = .035). There was no effect of tDCS (F (2,62) = .11, p = .90) nor interaction between tDCS and CBI (F (2,62) = .32, p = .73).

CONCLUSIONS

Given the connection between anxiety and MCS, results suggest that CBT techniques for somatic processes may show promise in treating conditions characterized by increased sensitivity to odors (e.g., MCS).

Differences in Multidisciplinary and Interdisciplinary Treatment Programs for Fibromyalgia: A Mapping Review

Fibromyalgia is a multifaceted chronic pain syndrome and the integration of different health disciplines is strongly recommended for its care. The interventions based on this principle are very heterogeneous and the difference across their structures has not been extensively studied, leading to incorrect conclusions when their outcomes are pooled. The objective of this mapping review was to summarize the characteristics of these programs, with particular focus on the integration of their components. We performed a search of the literature about treatments for fibromyalgia involving multiple disciplines on PubMed and Scopus. Starting from 560 articles, we included 22 noncontrolled studies, 10 controlled studies, and 17 RCTs evaluating the effects of 38 multidisciplinary or interdisciplinary interventions. The average quality of the studies was low. Their outcomes were usually pain intensity, quality of life, and psychological variables. We created a map of the programs based on the degree of integration of the included disciplines, which ranged from a juxtaposition of few components to a complex harmonization of different perspectives obtained through teamwork strategies. The rehabilitation programs were then thoroughly described with regard to the duration, setting, therapeutic components, and professionals included. The implications for future quantitative reviews are discussed.

Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine

Because of the dynamic and complex nature of chronic pain, successful treatment usually requires addressing behavioral, cognitive, and affective processes. Many adjunctive interventions have been implemented in fibromyalgia (FM) treatment, but few are supported by controlled trials. Herein, some of the more commonly used nonpharmacologic interventions for FM are described and the evidence for efficacy is presented. Clinical observations and suggestions are also offered, including using the principles outlined in the acronym ExPRESS to organize a comprehensive nonpharmacologic pain management approach.

Benefits of physical training in fibromyalgia and related syndromes

OBJECTIVE

To review the published information on physical training for fibromyalgia (FM) and related syndromes.

METHODS

A search of Medline literature (via Ovid and PubMed) with the following keywords: FM, chronic fatigue syndrome, therapy, rehabilitation, aerobic, exercise, and cognitive behavioral therapy. The reference lists of articles were examined for additional related articles.

RESULTS

Several studies investigated the benefits of graded exercise therapy for patients with FM or related syndromes. Although some systematic reviews have not established an unequivocal benefit of physical training, most authors report a benefit for patients with chronic pain or fatigue. Ideally, such a therapy should be a part of multidisciplinary program. Muscular rehabilitation is reserved for preventing the deconditioning syndrome often reported in patients and the vicious cycle of pain, avoidance and inactivity behaviors, or even kinesiophobia, deconditioning, incapacity and psychological distress.

CONCLUSION

This review emphasizes the relevance of graded physical training for treating FM and related syndromes. The development of rehabilitation centers, with experts able to propose a relevant therapy to patients with chronic pain or fatigue, should help alleviate this public health problem.

Mechanisms underlying development of spatially distributed chronic pain (fibromyalgia)

Chronic fibromyalgia (FM) pain is prevalent (estimated as high as 13%), predominantly affects women, and is associated with a variety of focal pain conditions. Ongoing FM pain is referred to deep tissues and is described as widespread but usually is maximally located within a restricted region such as the shoulders. Palpation of deep tissues reveals an enhanced nociceptive sensitivity that is not restricted to regions of clinical pain. Similarly, psychophysical testing reveals allodynia and hyperalgesia for cutaneous stimulation at locations beyond regions of clinical pain referral. The combination of widely distributed clinical pain and generalized hypersensitivity is highly disabling, but no satisfactory treatment is regularly prescribed. A thorough understanding of mechanisms will likely be required to develop and document adequate therapies. The generalized hypersensitivity associated with FM has focused considerable interest on central (CNS) mechanisms for the disorder. These include central sensitization, central disinhibition and a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis. However, the central effects associated with FM can be produced by a peripheral source of pain. Chronic nociceptive input induces central sensitization, magnifying pain, and it activates the HPA and the sympathetic nervous system. Chronic sympathetic activation indirectly sensitizes peripheral nociceptors and sets up a vicious cycle. Thus, it appears that central mechanisms of FM pain are dependent on abnormal peripheral input(s) for development and maintenance of this condition. A substantial literature defines peripheral-CNS-peripheral interactions that are integral to FM pain. These reciprocal actions and related phenomena of relevance to FM pain are reviewed here, leading to suggestions for testing of therapeutic approaches.

A comprehensive review of 46 exercise treatment studies in fibromyalgia (1988-2005)

The purpose of this review was to: (1) locate all exercise treatment studies of fibromyalgia (FM) patients from 1988 through 2005, (2) present in tabular format the key details of each study and (3) to provide a summary and evaluation of each study for exercise and health outcomes researchers. Exercise intervention studies in FM were retrieved through Cochrane Collaboration Reviews and key word searches of the medical literature, conference proceedings and bibliographies. Studies were reviewed for inclusion using a standardized process. A table summarizing subject characteristics, exercise mode, timing, duration, frequency, intensity, attrition and outcome variables was developed. Results, conclusions and comments were made for each study. Forty-six exercise treatment studies were found with a total of 3035 subjects. The strongest evidence was in support of aerobic exercise a treatment prescription for fitness and symptom and improvement. In general, the greatest effect and lowest attrition occurred in exercise programs that were of lower intensity than those of higher intensity. Exercise is a crucial part of treatment for people with FM. Increased health and fitness, along with symptom reduction, can be expected with exercise that is of appropriate intensity, self-modified, and symptom-limited. Exercise and health outcomes researchers are encouraged to use the extant literature to develop effective health enhancing programs for people with FM and to target research to as yet understudied FM subpopulations, such as children, men, older adults, ethnic minorities and those with common comorbidities of osteoarthritis and obesity.

In search of pharmacoeconomic evaluations for fibromyalgia treatments: a review

Fibromyalgia is characterised by chronic widespread pain of unknown aetiology and affects approximately 2% of the population. It can cause significant patient disability, sizeable economic costs, complex management decisions and controversy for healthcare providers. In lieu of uniformly approved treatments for fibromyalgia, patients may try multiple pharmacological and non-pharmacological therapies with questionable efficacy. The literature lacks pharmacoeconomic studies that balance the cost and benefit of interventions. In the absence of this work, cost outcomes are reviewed in this paper. Due to inconclusive results, further study is needed on fibromyalgia treatment cost-effectiveness. These analyses could provide useful information for policy and evidence-based practice guidelines toward optimal disease management. Medical professionals should be a driving force in understanding the clinical and economic challenges of fibromyalgia.

Educating patients: self-management approaches

PURPOSE

To review and evaluate approaches to educating patients with fibromyalgia syndrome (FMS).

METHODS

A narrative literature review was undertaken to summarize the published literature on patient education for FMS patients.

RESULTS

A number of studies contain specific education strategies while others are combined with exercise or movement therapies or cognitive-behavioural therapy.

CONCLUSIONS

Self-efficacy provides an effective theoretical model from which to understand how patients change as a result of education strategies that focus on self-management. Programmes that combine education with cognitive-behavioural techniques and exercise are most effective in enhancing self-efficacy and decreasing symptoms of FMS.

Rehabilitation approaches in fibromyalgia

PURPOSE

This paper provides an overview of the evidence for the principal approaches taken to the rehabilitation of patients with fibromyalgia (FM): exercise, psychologically-based approaches, multimodal approaches, self-management approaches, and complementary and alternative therapies.

METHOD

A review of current published evidence.

RESULTS

Owing to factors such as methodological shortcomings of existing studies, and the lack of evidence on individual modalities, it is difficult to draw definitive conclusions as to which is the most appropriate rehabilitation approach in FM. However, there is growing evidence for the role of exercise training, and clear indications that if appropriately prescribed, this can be undertaken without adverse effects. Similarly, psychologically-based interventions such as cognitive-behavioural therapy have received some support from the literature. Evidence for other interventions is more equivocal.

CONCLUSIONS

It appears that a combination of interventions, in a multimodal approach (e.g., exercises combined with education and psychologically-based interventions) is the most promising means of managing patients with FM.

Sustained improvement produced by nonpharmacologic intervention in fibromyalgia: results of a pilot study

OBJECTIVE

The aim of this pilot study was to examine the practicality of delivering a package of nonpharmacologic, behavioral-based treatment, previously found to be effective in chronic back pain, to patients with fibromyalgia (FM) and to assess the efficacy of the intervention using a range of outcome measures up to 4 months posttreatment.

METHODS

Participants with FM (n = 28) formed a single group for 8 sessions at weekly intervals. Each session comprised an education/cognitive-behavioral component, formal relaxation/meditation training, and instruction in a Chinese movement therapy (Qi Gong).

RESULTS

Twenty of 28 subjects completed at least 5 of the 8 sessions. Significant improvement was seen in the Fibromyalgia Impact Questionnaire and a range of other outcome measures including tender points and pain threshold. Improvement was sustained 4 months after the end of the intervention.

CONCLUSION

A simple behavioral intervention using large groups can be administered to subjects with FM and appears to produce sustained benefit in a range of outcomes. Controlled trials are currently being planned.

Psychological and behavioural therapies in fibromyalgia and related syndromes

Psychological and behavioural therapies are being applied to patients with fibromyalgia (FM) with increasing frequency. The rationale for including psychological therapies is not for the treatment of co-morbid mood disorders, but rather to manage the many non-psychiatric psychological and social factors that comprise pain perception and its maintenance. This chapter reviews the involvement of mental health professionals under both the biomedical and biopsychosocial models of illness and describes cognitive behavioural therapy (CBT), a commonly used form of psychological therapy in the management of chronic pain conditions. The empirical literature supports the use of CBT with FM in producing modest outcomes across multiple domains, including pain, fatigue, physical functioning and mood. Greatest benefits appear to occur when CBT is used adjunctively with exercise. While the benefits are not curative or universally obtained by all patients, the benefits are sufficiently large to encourage future refinement of CBT for this population of patients.

"I am allowed to be myself": women with chronic muscular pain being recognized

AIMS

Since 1992, the authors have completed 11 treatment groups for women with chronic muscular pain. The programme includes movement training and group discussions. Qualitative data indicate that the participants valued the experience of being recognized in the groups as a crucial and beneficial effect of the treatment. In the present article, this finding is examined in more detail by studying the types of action and interaction that the women considered to have benefited from by participating in group treatment.

METHODS

Data are drawn from an action research project and the material originates from three treatment groups where 24 participants completed the programme. Qualitative data originating from five focus group interviews are analysed using Giorgi's principles of phenomenological analysis.

RESULTS

The women described different concrete aspects of interaction and awareness illustrating psychologist Løvlie Schibbye's theoretical perspectives of a recognizing attitude: listening, understanding, acceptance, tolerance, and confirmation. The women tell how they themselves have experienced these expressions of recognition from other group members and from the group leaders.

CONCLUSIONS

The women confirmed that recognition had an important effect on how much they benefited from the treatment programme. The need for mutual recognition draws attention to the power and possible abuse of power inherent in human relationships, as exemplified by the relationship between the patient and healthcare providers. An explicit presentation of the human and moral value behind the treatment programme represents a challenge.

Encountering the continuing challenges for women with chronic pain: recovery through recognition

This work is based on experiences from a group treatment for women with chronic musculoskeletal pain. The authors explored the nature and consequences of the reported benefits from being met with recognition in the groups, focusing the potential usefulness in everyday life. In-depth interviews of six participants of various age and backgrounds were conducted. The women's answers reflected how recognition had enhanced strength, confidence, and awareness expressed as increased bodily, emotional, and social competence. This competence provided tools to handle their pain and illness. Achieving the sense of a better life with chronic pain represents an important recovery process. Because of the normative and gendered way the term "coping(ability)" has been used, the authors introduce recovery competence as a more fruitful concept.

Person-centered approach to care, teaching, and research in fibromyalgia syndrome: justification from biopsychosocial perspectives in populations

OBJECTIVES

To describe complex interactions of multiple factors believed to contribute to fibromyalgia syndrome (FMS) at a person-centered level to enhance approaches to care, teaching, and research. The main factors addressed were central nervous system sensory sensitization, autonomic nervous system (ANS) activation, neurohumoral perturbations, and psychosocial and environmental stressors. A person-centered approach is defined as attention to major biopsychosocial issues of affected individuals.

METHODS

Literature on classification, mechanistic pathways, course and outcomes, and management of FMS was reviewed to assess applications of person-centered approaches to care, teaching, and research. Various biopsychosocial influences were considered in relation to the heterogeneous subjective manifestations of this illness, including central hyperalgesia, ANS and other neurohumoral perturbations, functional hyperexcitability, nonrestorative sleep, and psychologic distress.

RESULTS

A person-centered approach to FMS can expand on and strengthen traditional biomedical concepts. Adding such a focus can help to untangle current controversies in the course, outcomes, and treatment of FMS. A person-centered approach can also help in the subgrouping of affected patients for greater specificity in care programs and in improved clinical investigations. In the biomedical model, diverse symptoms of FMS are often addressed separately and apart from their interconnectedness and linkages to the patient's individualized biopsychosocial factors. However, the causes of FMS symptomatology are not likely to be caused by uniform biologic abnormalities across populations. Rather, the syndrome likely results from personal reactivities to varied multifactorial biopsychosocial influences. Common denominators among individuals may include varying degrees of ANS activation (or personal susceptibility to ANS activation), nonrestorative sleep, negative affectivity, and other central pain sensitization mechanisms, among the pathways reviewed.

CONCLUSIONS

Innovative analytical methodologies will need to be developed to more effectively investigate complex interacting biopsychosocial dynamics at a person-centered level, including qualitative research, and multifactorial and multilevel techniques. Adding person-centered approaches to biopsychosocial concepts of FMS promises to show new physiopathogenetic insights and more effective treatment than current biomedical models alone. Person-centered approaches enhance patient-physician relationships and help prioritize patients' goals in mutually derived treatment plans.

A realistic approach to managing patients with fibromyalgia

Fibromyalgia syndrome is common and variable in impact, with some patients having a milder and shorter duration of symptoms and others suffering significant and prolonged pain. Disability also varies. It is thought that the syndrome arises from a disordered neurophysiology that, through links to central control inputs, involves emotions, thoughts, and cognitions. Social and psychological sequelae contribute to and result from this process. The biopsychosocial model of disease epitomizes fibromyalgia. Although management may be difficult at times, and much needs to be done, the growing appreciation of strategies that use this described model and the knowledge of the potential reversibility of the syndrome are resulting in improved outcomes.

[What happens to the fibromyalgia syndrome?]

OBJECTIVE

To realize a clarification about fibromyalgia, attempting to consider diagnostic criteria, prevalence, pathophysiology and therapeutic approach.

METHOD

A systematic literature search was conducted to select articles about fibromyalgia and connected diseases. The database are Premedline, Medline and Medlineplus.

RESULTS

Fifty-eight articles about fibromyalgia and twelve articles about connected diseases were selected to realize this review of literature.

DISCUSSION

Fibromyalgia constitutes a syndrome characterized by widespread musculo-skeletal pain, present above the waist and below the waist and in the axial skeleton. Widespread pain must have been present for at least three months. "Spasmophilie", chronic fatigue syndrome and myofascial syndrome represent diseases connected with fibromyalgia: differential diagnosis must be established. Researches related to fibromyalgia suggest a reduction of muscular performances associated with histological and biochemical anomalies. Patients are characterized by shorter and nonrestorative sleep. Psychological, neuroendocrine and central alterations appear often associated with fibromyalgia. The reduction of pressure tolerance and pain thresholds may be linked to the alterations of neuroendocrine substances. Literature recommend a multidisciplinary therapeutic approach in management of fibromyalgia.

CONCLUSION

The pathophysiologic mechanisms in fibromyalgia appear multiple and interdependent. With the aim to optimizing treatment, investigations are necessary to determine biochemical repercussions of various therapeutic approaches.

Utilizing exercise to affect the symptomology of fibromyalgia: a pilot study

Fibromyalgia (FM), a rheumatological disorder of unknown origin, is characterized by both physical and psychological symptoms. Although inconclusive results have been reported for most treatment modalities, exercise appears to have universal support for decreasing the myriad of symptoms associated with FM. Weaknesses in the literature, however, prevent conclusive statements regarding exercise prescription and concomitant impact on FM symptomology.

PURPOSE

The current pilot study attempted to examine the effect of a 24-wk walking program at predetermined intensities on FM.

METHODS

Initial design was a randomized control trial with high- and low-intensity exercise groups, and a control group. Subsequent nonrandomized control trials were based on actual exercise behavior.

RESULTS

No differences between initial groups were identified. By collapsing groups, heart rate (HR) decreased (P < 0.05) weeks 0-12. Functional impairments were reduced 54% weeks 0-24, with exercise having a large impact (omega2 = 0.30) on this decrease. By reassigning groups, impact of FM on current health status decreased in the low-intensity group (P < 0.05) and increased in the high-intensity group (P < 0.02) weeks 0-24. Omega squared indicated strong influence of exercise on pain (omega2 = 0.51), with greater pain in the high-intensity group.

CONCLUSIONS

A larger number of subjects and direct supervision of the training program to increase compliance is necessary to clarify the effects of a walking program on the manifestations of FM. Results indicate that intensity of the walking program is an important consideration. Individuals with FM can adhere to low-intensity walking programs two to three times per week, possibly reducing FM impact on daily activities.

Evidence for metabolic abnormalities in the muscles of patients with fibromyalgia

Widespread muscle pain, fatigue, and weakness are defining characteristics of patients with fibromyalgia (FM). The aim of this review is to summarize recent investigations of muscle abnormalities in FM, which can be classified as structural, metabolic, or functional in nature. Histologic muscle abnormalities of membranes, mitochondria, and fiber type have been well described at both the light microscopic and ultrastructural levels. These structural abnormalities often correlate with biochemical abnormalities, defective energy production, and the resultant dysfunction of FM muscles. The observed abnormalities in FM muscles are consistent with neurologic findings and disturbances in the hypothalamic-pituitary-adrenal axis. Functional changes in FM muscles are assessed most directly by strength and endurance measurements, but pain and psychologic factors may interfere with accurate assessments. To compensate for diminished effort, the decreased efficiency of the work performance by patients with FM can be verified from P-31 magnetic resonance spectroscopy (MRS) data by calculation of the work/energy-cost ratio for various tasks. In the disease course, muscle abnormalities may be elicited by intrinsic changes within the muscle tissue itself and/or extrinsic neurologic and endocrine factors. The accurate assignment of intrinsic or extrinsic factors has been substantially clarified by a recent surge of experimental findings. Irrespective of the multifaceted causes of muscle dysfunction and pain, an in-depth understanding of the muscle defects may provide ideas for characterization of the underlying pathogenesis and development of new therapeutic approaches for fibromyalgia syndrome.

A meta-analysis of fibromyalgia treatment interventions

OBJECTIVE

To evaluate and compare the efficacy of pharmacological and nonpharmacological treatments of fibromyalgia syndrome (FMS).

METHODS

This meta-analysis of 49 fibromyalgia treatment outcome studies assessed the efficacy of pharmacological and nonpharmacological treatment across four types of outcome measures-physical status, self-report of FMS symptoms, psychological status, and daily functioning.

RESULTS

After controlling for study design, antidepressants resulted in improvements on physical status and self-report of FMS symptoms. All nonpharmacological treatments were associated with significant improvements in all four categories of outcome measures with the exception that physically-based treatment (primarily exercise) did not significantly improve daily functioning. When compared, nonpharmacological treatment appears to be more efficacious in improving self-report of FMS symptoms than pharmacological treatment alone. A similar trend was suggested for functional measures.

CONCLUSION

The optimal intervention for FMS would include nonpharmacological treatments, specifically exercise and cognitive-behavioral therapy, in addition to appropriate medication management as needed for sleep and pain symptoms.

Pain management strategies and team approach

Multimodal pain management programmes have been used for chronic pain conditions such as low back pain or headache for many years with good results. However their effectiveness for treating fibromyalgia has only recently been established and with respect to long-term outcome the evidence is still not convincing. Recent findings, about abnormalities in pain control and neuroendocrine systems, help to understand the symptomatology of fibromyalgia and give theoretical support for these treatment concepts. They might also explain why secondary phenomena like depression, anxiety, deconditioning and disability can make it harder to treat the condition at a chronic stage. The ingredients of such multimodal programmes are described and evidence for their effectiveness is presented.

Differential responses by psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment

OBJECTIVES

To evaluate differential treatment responses among 3 empirically derived, psychosocial subgroups of patients with fibromyalgia syndrome to a standard interdisciplinary treatment program.

METHOD

Patients were classified into 1 of 3 psychosocial groups on the basis of their responses to the Multidimensional Pain Inventory. Forty-eight patients completed a 6 one-half-day outpatient treatment program consisting of medical, physical, occupational, and psychological therapies spaced over a period of 4 weeks (3 sessions the first week followed by 1 session per week for the next 3 consecutive weeks).

RESULTS

Statistically significant reductions were observed in pain, affective distress, perceived disability, and perceived inteference of pain in the patients characterized by poor coping and high level of pain ("dysfunctional" group). In contrast, individuals who were characterized by interpersonal difficulties ("interpersonally distressed" group) exhibited poor responses to the treatment. "Adaptive copers," the third group, revealed significant improvements in pain but due to low pretreatment levels of affective distress and disability showed little improvement on these outcomes.

CONCLUSIONS

The results provided support for the hypothesis that customizing treatment based on patients' psychosocial needs will lead to enhanced treatment efficacy. They also emphasize the importance of using appropriate outcome criteria, as low levels of problems at baseline are not likely to show significant changes following any treatment.

Comparison of integrated group therapy and group relaxation training for fibromyalgia

OBJECTIVE

The efficacy of an integrated, psychological treatment program was tested in a controlled study involving 27 patients with chronic musculoskeletal pain (fibromyalgia).

DESIGN

The experimental treatment program consisted of instruction in various self-help techniques (e.g., cognitive behavioral strategies, relaxation, physical exercises) as well as information on chronic pain. Control groups were instructed only in autogenic training. Measures of pain, daily activities, general symptoms, and psychological functioning were assessed before and after treatment, as well as at 4 months after termination of therapy (follow-up).

RESULTS

At the end of treatment, 7 patients from the experimental group and 2 from the control group showed significant clinical improvement in 3 of 6 parameters (NS). At follow-up, the improvement was still present in 5 experimental cases but in none of the controls (p = 0.024). Successful patients had been sick for a shorter period of time and were less impaired by their condition.

CONCLUSIONS

Psychological interventions in combination with physiotherapy can be effective in treating fibromyalgia patients, especially if applied early.

Skeletal muscle abnormalities in patients with fibromyalgia

Widespread muscle pain and tender points are the most common complaints of fibromyalgia patients, and the underlying mechanisms responsible for these symptoms have been studied intensively during the past decade. It has been suggested that fatigue and pain may lead to decreased levels of physical activity in many patients. The resulting deconditioned state may itself contribute to muscle abnormalities. Associated symptoms such as disturbed sleep, anxiety, depression, or irritable bowel also may have a negative impact on muscle function and level of daily activities. The important interactions between the central nervous and musculoskeletal systems may involve another element, the neuroendocrine stress-response system. This review will consider both the current state of knowledge and also future studies which might be designed to answer more effectively the outstanding questions regarding the underlying pathogenesis of fibromyalgia.

Interdisciplinary treatment for fibromyalgia syndrome: clinical and statistical significance

OBJECTIVES

The primary purposes of the study were to: evaluate the treatment efficacy of an outpatient, interdisciplinary treatment program for fibromyalgia syndrome (FMS); examine whether treatment gains would be sustained for 6 months following the treatment; assess whether improvements were clinically significant; and delineate the factors associated with clinically significant improvement in pain severity.

METHODS

Sixty-seven FMS patients completed a 4-week outpatient program consisting of medical, physical, psychologic, and occupational therapies. Six-month followup data were available for 66% of treated patients.

RESULTS

Comparisons between pretreatment and posttreatment measures revealed significant improvements in pain severity, life interference, sense of control, affective distress, depression, perceived physical impairment, fatigue, and anxiety; however, there was no improvement in interpersonal relationships or general activities. Clinically significant improvement in pain severity, using the Reliable Change Index, was obtained by 42% of the sample and was predicted by the pretreatment levels of depression, activity, perceived disability, solicitous responses of significant others, and idiopathic onset. Pretreatment level of pain severity was not a significant predictor of the degree of pain improvement. Comparisons among pretreatment, posttreatment, and 6-month followup data revealed that the patients maintained treatment gains in pain, life interference, sense of control, affective distress, and depression. However, the quadratic polynomial analysis revealed that relapse occurred in the subjective rating of fatigue.

CONCLUSIONS

The results suggest that, overall, an outpatient interdisciplinary treatment program was effective in reducing many FMS symptoms. Treatment gains tended to be maintained for at least 6 months. However, there were large individual differences in response to treatment. These results suggest that identification of subgroups of FMS patients and their specific clinical characteristics may be useful for maximizing treatment efficacy.

Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial

OBJECTIVE

To compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of fibromyalgia.

METHODS

Subjects (n = 119) were randomly assigned to one of 4 groups: 1) biofeedback/relaxation training, 2) exercise training, 3) a combination treatment, or 4) an educational/attention control program.

RESULTS

All 3 treatment groups produced improvements in self-efficacy for function relative to the control condition. In addition, all treatment groups were significantly different from the control group on tender point index scores, reflecting a modest deterioration by the attention control group rather than improvements by the treatment groups. The exercise and combination groups also resulted in modest improvements on a physical activity measure. The combination group best maintained benefits across the 2-year period.

CONCLUSION

This study demonstrates that these 3 treatment interventions result in improved self-efficacy for physical function which was best maintained by the combination group.

Multidisciplinary group programs to treat fibromyalgia patients

There are three realities that need to be understood by both clinicians and patients: (1) fibromyalgia is a complex chronic pain condition and current treatment is palliative rather than curative; (2) the major aim of treatment is to improve function, not abolish pain; and (3) a cycle of chronic pain, stress, and psychological arousal often generates a set of secondary symptoms. These secondary symptoms provide a positive feedback loop that is amenable to modification by cognitive-behavioral techniques. Multidisciplinary group treatment programs are especially suited to such techniques; their aim should be to maximize subsequent clinician-patient interactions. Thus, a current concept of optimal management is a blend of multidisciplinary group therapy and individualized clinician-based treatment.