ROME -- A tailored combination of cognitive-behavioral therapy and physical exercise training has achieved the largest treatment benefit ever reported for fibromyalgia in a randomized, placebo-controlled trial.
The durability of the results was particularly impressive. The large improvements in psychological and physical functioning that were documented at the end of the 8-week treatment program were maintained at the 6-month follow-up, Saskia van Koulil said.
The success of this customized treatment approach hinged upon a two-stage screening process. First, patients who have had their fibromyalgia for fewer than 5 years and were at high risk of long-term dysfunction were selected because prior studies indicated that such individuals tend to have better treatment outcomes in general.
Within this group of high-risk patients, specific cognitive-behavioral patterns seemed to drive their fibromyalgia pain and disability. It is possible to screen for these patterns of thought and behavior. One school of thought among clinical psychologists, including Ms. van Koulil, holds that there are two main patterns: pain avoidance and pain persistence. The treatment programs for the two are quite different, explained Ms. van Koulil of St. Radboud University Medical Center in Nijmegen, the Netherlands.
The high treatment success rate in this randomized trial validated this concept of the pain-avoidance and pain-persistence fibromyalgia subtypes, she continued.
In her experience, close to two-thirds of patients with fibromyalgia of fewer than 5 years' duration have a high-risk profile. This is characterized by high levels of anxiety and/or negative mood on standard measures of distress, along with worse physical functioning, greater impact of fibromyalgia on daily life, and obvious maladaptive cognitive-behavioral patterns such as high levels of helplessness and worrying. This high-level psychological distress is an indicator of treatment motivation, according to Ms. van Koulil.
In the randomized trial, 158 high-risk fibromyalgia patients (95% of whom were women) were evaluated with a brief screening instrument for pain-avoidance behavior. Those with a high score were assigned to the pain-avoidance treatment group or a wait-list control arm, whereas patients with a low score were randomized to the pain-persistence group or the control arm.
The pain-avoidance subtype of fibromyalgia is characterized by fear of pain, hypervigilance, catastrophiz-ing, and zealous avoidance of pain. In contrast, the pain-persistence subtype is characterized by an overactive lifestyle and low levels of pain avoidance. In fact, these highly self-demanding patients tend to ignore pain, ignore their physical limits, and display high levels of task persistence. Both subtypes end up via different routes at the same place, which is marked by functional disability, psychologic distress, fatigue, …