Fibromyalgia--which is the best treatment? A personalized, comprehensive, ambulatory, patient-involved management programme

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.

Development and evaluation of a cognitive-behavioral intervention for juvenile fibromyalgia

OBJECTIVE

To describe the development and test the efficacy of a cognitive-behavioral intervention (CBT) for juvenile fibromyalgia.

METHOD

Sixty-seven children with fibromyalgia and their parents were recruited to participate in an 8-week intervention that included modules of pain management, psychoeducation, sleep hygiene, and activities of daily living. Children were taught techniques of cognitive restructuring, thought stopping, distraction, relaxation, and self-reward. Additionally, they kept daily pain and sleep diaries. Children completed questionnaires of pre- and post-treatment measuring physical status and psychological functioning.

RESULTS

Following CBT, children reported significant reductions (p < .006) in pain, somatic symptoms, anxiety, and fatigue, as well as improvements in sleep quality. Additionally, children reported improved functional ability and had fewer school absences.

CONCLUSION

Children with fibromyalgia can be taught CBT strategies that help them effectively manage this chronic and disabling musculoskeletal pain disorder.

The Potential of Treatment Matching for Subgroups of Patients With Chronic Pain

A large and diverse number of treatments have been shown to be effective in reducing pain and other symptoms for a minority but statistically significant number of patients in different chronic pain syndromes. The means by which such different treatments achieve similar outcomes is not well understood. In this paper, the importance of considering patient heterogeneity for those who may be diagnosed with the same medical syndrome is discussed. The author suggests that the lack of satisfactory treatment outcomes for the treatments of chronic pain syndromes may be accounted for by the patient homogeneity myth--the assumption that all patients with the same medical diagnosis are similar on all important variables. The importance of subdividing (splitting) patients into meaningful groups is described. Studies presenting data on the identification of patient subgroups based on psychosocial and behavioral characteristics and the reliability and validity of this approach are presented. Some initial attempts to demonstrate the potential for matching treatments to patient subgroups are described.

A pilot study of body awareness programs in the treatment of fibromyalgia syndrome

OBJECTIVE

To compare in a pilot study the effect of two physical therapies, the Mensendieck system (MS) and body awareness therapy (BAT) according to Roxendal, in fibromyalgia patients and to investigate differences in effect between the two interventions.

METHODS

Twenty female patients were randomized to either MS or BAT in a program lasting 20 weeks. Evaluations were tender point examination and questionnaires, including visual analog scales (pain intensity at worst site, muscular stiffness, evening fatigue, and global health), Fibromyalgia Impact Questionnaire (FIQ), Coping Strategies Questionnaire, Quality of Life Scales, Arthritis Self-Efficacy Scale (ASES), and disability before, immediately after, and at 6 and 18 months follow-up.

RESULTS

The BAT group had improved global health at 18 months follow-up, but lower results than the MS group. The MS group had improved FIQ, ASES other symptoms, and pain at worst site at 18 months follow-up.

CONCLUSION

In the present pilot study, MS was associated with more positive changes than BAT.

Subgrouping of fibromyalgia patients on the basis of pressure-pain thresholds and psychological factors

OBJECTIVE

Although the American College of Rheumatology (ACR) criteria for fibromyalgia are used to identify individuals with both widespread pain and tenderness, individuals who meet these criteria are not a homogeneous group. Patients differ in their accompanying clinical symptoms, as well as in the relative contributions of biologic, psychological, and cognitive factors to their symptom expression. Therefore, it seems useful to identify subsets of fibromyalgia patients on the basis of which of these factors are present. Previous attempts at identifying subsets have been based solely on psychological and cognitive features. In this study, we attempt to identify patient subsets by incorporating these features as well as the degree of hyperalgesia/tenderness, which is a key neurobiologic feature of this illness.

METHODS

Ninety-seven individuals meeting the ACR criteria for fibromyalgia finished the same battery of self-report and evoked-pain testing. Analyzed variables were obtained from several domains, consisting of 1) mood (evaluated by the Center for Epidemiologic Studies Depression Scale [for depression] and the State-Trait Personality Inventory [for symptoms of trait-related anxiety]), 2) cognition (by the catastrophizing and control of pain subscales of the Coping Strategies Questionnaire), and 3) hyperalgesia/tenderness (by dolorimetry and random pressure-pain applied at suprathreshold values). Cluster analytic procedures were used to distinguish subgroups of fibromyalgia patients based on these domains.

RESULTS

Three clusters best fit the data. Multivariate analysis of variance (ANOVA) confirmed that each variable was differentiated by the cluster solution (Wilks' lambda [degrees of freedom 6,89] = 0.123, P < 0.0001), with univariate ANOVAs also indicating significant differences (all P < 0.05). One subgroup of patients (n = 50) was characterized by moderate mood ratings, moderate levels of catastrophizing and perceived control over pain, and low levels of tenderness. A second subgroup (n = 31) displayed significantly elevated values on the mood assessments, the highest values on the catastrophizing subscale, the lowest values for perceived control over pain, and high levels of tenderness. The third group (n = 16) had normal mood ratings, very low levels of catastrophizing, and the highest level of perceived control over pain, but these subjects showed extreme tenderness on evoked-pain testing.

CONCLUSION

These data help support the clinical impression that there are distinct subgroups of patients with fibromyalgia. There appears to be a group of fibromyalgia patients who exhibit extreme tenderness but lack any associated psychological/cognitive factors, an intermediate group who display moderate tenderness and have normal mood, and a group in whom mood and cognitive factors may be significantly influencing the symptom report.

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.

Effects of staphylococcus toxoid vaccine on pain and fatigue in patients with fibromyalgia/chronic fatigue syndrome

Positive results of pilot studies of the effect of staphylococcus toxoid vaccine in patients with fibromyalgia and chronic fatigue syndrome were the incitement to the present, placebo-controlled study. It included 28 patients who fulfilled the criteria for both fibromyalgia and chronic fatigue syndrome. The effect of vaccination with a staphylococcus toxoid was compared with the effect of injections of sterile water. Psychometric assessment was made using 15 items from the comprehensive psychopathological rating scale (CPRS), Zung's self-rating depression scale and clinical global impressions (CGI). The visual analogue scale (VAS) was used to measure pain levels, and a hand-held electronic pressure algometer was used to measure pressure pain thresholds. Significant improvement was seen in seven of the 15 CPRS items in the vaccine group when pretreatment values were compared to post-treatment values. In CPRS <<fatiguability>>, there were significant intergroup differences, and in CPRS <<pain>> intergroup differences bordered on significance. There was no significant improvement in CPRS items in the placebo group. Clinical global impressions showed significant improvement in the vaccine-treated group, and VAS did so in both groups. In a follow-up study of 23 patients, the vaccine treatment was continued for 2-6 years. Fifty percent were rehabilitated successfully and resumed half-time or full-time work. The results of this study support the authors>> hypothesis that treatment with staphylococcus toxoid may be a fruitful strategy in patients with fibromyalgia and chronic fatigue syndrome. Copyright 1998 European Federation of Chapters of the International Association for the Study of Pain.

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.

The relationship between fibromyalgia and major depressive disorder

Looking at the results of the seven types of studies discussed previously, it appears that there is strong evidence for an association between fibromyalgia and major depressive disorder on the basis of (1) overlapping symptomatology, (2) similar pattern of comorbid disorders, and (3) high rates of major depressive disorder among relatives of patients with fibromyalgia. There is additional support for an association on the basis of responses to psychological tests and rating scales and the high lifetime rates of mood disorders in fibromyalgia. Two lines of evidence, (1) response to antidepressant medications and (2) response to biologic tests, offer little evidence either for or against an association. On balance, then the weight of the evidence favors an association between fibromyalgia and major depressive disorder. We therefore turn to an analysis of the nature of the association.

Lack of correlation between the mean tender point score and self-reported pain in fibromyalgia

OBJECTIVES

To study the validity and nature of self-assessed symptoms among patients with fibromyalgia syndrome (FMS) and to compare our data with findings reported in the US. To determine whether tender point scores correlate with self-reported pain and other symptoms and to study the influence of disease duration.

METHODS

Tender point scores were assessed in 113 consecutive patients with FMS. All patients completed 2 self-assessment questionnaires (an extended Campbell list, the Enschede Fibromyalgia Questionnaire, and the Dutch Arthritis Impact Measurement Scales).

RESULTS

The self-assessed symptoms of the Dutch FMS patients seem to be valid and are comparable with those of American patients. No association between disease duration and number of self-reported symptoms was found. An association between self-reported pain and mean tender point score was lacking for patients with disease of shorter duration and was weak for patients with disease of longer duration.

CONCLUSIONS

The use of a self-report questionnaire for patients with FMS is feasible and appears to be valid. Tender point scores and self-reported pain represent very different aspects of pain in FMS.

Effects of aerobic exercise versus stress management treatment in fibromyalgia. A 4.5 year prospective study

To determine and compare short- and long-term effects of aerobic exercise (AE), stress management treatment (SMT), and treatment-as-usual (TAU) in fibromyalgia, 60 patients were randomized to 14 weeks of treatment by either AE, SMT or TAU. Outcome measures at baseline, midway through treatment, at treatment completion, and at 4 year follow up included a patient made drawing of pain distribution, dolorimetry of tender points, ergometer cycle test, global subjective improvement, and VAS registrations of: pain, disturbed sleep, lack of energy, and depression. Both AE and SMT showed positive short-term effects. AE was the overall most effective treatment, despite being subject to the most sceptical patient attitude prior to the study. At follow up, there were no obvious group differences in symptom severity, which for AE seemed to be due to a considerable compliance problem.

Fibromyalgia--the effect of relaxation and hydrogalvanic bath therapy on the subjective pain experience

In the present study, two established non-medicinal treatment methods are compared with regard to their effect on various psychological pain parameters in patients with fibromyalgia. Twelve patients underwent hydrogalvanic baths, 13 patients the Jacobson relaxation training. Statistical evaluation showed only one significant difference in the different dimensions of pain measured at the beginning and end of the therapy. In comparison with patients receiving Jacobson-therapy, there is a significantly higher decrease in pain intensity in the period from breakfast till lunch in patients receiving bath-therapy. Apart from this, no differences between the two treatment groups could be found, either in the quality of pain, the psychological symptoms accompanying it, in sleep quality or in pain behaviour.

Physical medicine and rehabilitation approaches to the management of myofascial pain and fibromyalgia syndromes

In summary, we have presented the physical medicine and rehabilitation medicine approaches for treating patients with fibromyalgia and the myofascial pain syndromes. The importance of approaching these patients from a holistic and multidisciplinary standpoint has been stressed, paying attention to the physical, emotional, spiritual and behavioural components of the presentation. Although fibromyalgia and the myofascial pain syndromes are two distinct conditions, they often overlap, and when they do the myofascial component should be treated first. However, the clinician should remember that pain, tissue dysfunction and disability from pain are all separate issues and should be treated as such. Treatment in all cases should be individualized and comprehensive. It is imperative to make the patient an active participant in his care and to establish mutually agreed upon goals at the outset of treatment. It is important to establish an adequate and appropriate home exercise programme to supplement formal treatment. A good home exercise programme should stress both stretching and strengthening. Formal treatment programmes should not be geared to pain relief alone but rather to restoration of function, and return to functioning lifestyles. The clinician has available a wide array of modalities and tools to control pain, but the major goal of all treatment programmes is to restore individuals to functional lifestyles and to promote both physical and emotional flexibility, balance and 'wellness'. It is often necessary to involve the family unit as an inherent and critical part of the treatment team, particularly with the patient who continues to be dysfunctional despite apparently appropriate treatment. Although treatment always starts at the tissue level, a good treatment programme must always be holistic in nature and treat the tissues, the patient as a whole, and his or her environmental stressors and contingencies as well.

Education programmes for fibromyalgia patients: description and evaluation

A firm theoretical basis for patient education in rheumatic disease care has been built up over the past 10 to 15 years. Education in self-management has enabled patients to control symptoms and become partners in care with their health providers. Education for fibromyalgia patients has come to the foreground during the last 5 years as health professionals have come to understand the syndrome better and recognize the role that stress plays in the exacerbation of symptoms. A few controlled trials of various strategies, such as aerobic conditioning and cognitive-behavioural techniques, have been reported recently. All have shown significant benefits to patients with fibromyalgia. Only one controlled trial has studied the effects of a self-management education programme alone. The results of this programme were positive. Self-efficacy and life quality were enhanced. This programme and an uncontrolled programme that integrated many strategies have shown some of the first positive long-term indications that patients who are treated intensively for even a short time can continue to improve as they practice self-management techniques. There is still a need for further documentation of non-drug treatment strategies and especially further research into who is helped by which strategies, the optimal length of time for a programme, and the need for ongoing treatment.