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Focused therapy may ease fibromyalgia pain: combination of customized behavioral therapy and exercise may be the key to symptom relief.

Multiple therapies, including exercise, cognitive behavioral therapy (CBT) and medication, have long been prescribed to treat fibromyalgia (FM), a chronic disease that causes muscle and joint pain and tenderness throughout the body, as well as fatigue, sleep disturbance, cognitive and memory problems and symptoms of depression and anxiety.

However, more focused treatment specifically customized for the individual yields more positive and longer-lasting results, particularly when intervention is relatively early in the disease process, according to a recent Dutch study led by Saskia van Koulil, MSc, and colleagues, Radboud University Nijmegen Medical Center, Netherlands.

In this study, 158 participants who had been diagnosed with FM within the previous five years were divided into two groups: those who avoided any activity, fearing it would cause pain (pain avoidance [PA], 84 patients), and those who continued with their activities despite pain (pain-persistence [PP], 74 patients).


In both groups, patients were randomly assigned to either 16 twice-weekly, customized, two-hour sessions of CBT plus two hours of exercise training or a wait list for treatment (control group). CBT is used to help people recognize negative thought patterns and emotional responses and teaches them practical ways to change their behavior.

TAILORED THERAPY. The patients in the PA group had CBT sessions to help them deal with their fear of pain and to set goals for increasing daily activities. For those in the PP group, CBT training consisted of setting realistic goals and learning how to pace daily activities without overtaxing themselves.

For both groups, the CBT sessions aimed at reducing the daily perceived cognitive, behavioral, emotional and social consequences of pain and its accompanying complaints. Exercise training was geared to increasing each participant's level of physical fitness and flexibility, and consisted of relaxation training, aerobic exercise (cycling or gymnastics), and hydrotherapy or anaerobic exercise (strength and flexibility training, walking).

Physical and psychological outcomes were measured at baseline, after the 16 sessions of treatment, and after six months. Significant improvements were found on all levels--pain, fatigue, functional disability, mood and anxiety--relative to the control group.

OUTCOME. After six months, 66 percent of treated patients had "clinically significant" improvements compared to 33 percent of the wait-list patients. And 62 percent of the treated patients had psychological improvements compared to 33 percent in the control group.

The study lacked a control group that received standard CBT-plus exercise, however, which would have provided another measure against which to gauge the efficacy of the customized CBT-plus exercise therapy.

Researchers concluded that customizing treatment for fibromyalgia patients improves both short- and long-term outcomes and "reduces the burden for patients and society."


* Fibromyalgia is difficult to understand and diagnose, and is often mistaken for other diseases that cause muscle and joint pain and tenderness throughout the body. Fibromyalgia affects about five million U.S. adults, most commonly women in middle age.

* While causes are difficult to pinpoint, some people have a genetic predisposition to fibromyalgia along with other concurrent conditions. Physical stressors, such as arthritis or trauma, are suspected triggers; emotional stressors also are thought to have a role.

* Treatment includes medications that can improve sleep as well as relieve pain, such as prega-balin (Lyrica) and gabapentin (Neurontin), which block overactivity of nerve cells involved in pain transmission, and cyclobenzaprine (Flexeril) and amitriptyline (Elavil). Newer drugs such as duloxetine (Cymbalta) and milnacipran (Savella) also can help relieve pain.

* Frequently, yoga, massage and acupuncture help relieve stiffness and muscle pain. Regular exercise is an important component of treatment.


DAN G. BLAZER, MD, PhD, Professor-Department of Community & Family Medicine, Duke

More Specific Therapies Lead to a Better Quality of Life

"Fibromyalgia is both a painful and frustrating disorder experienced by many people. The frustration derives in part from a lack of clear evidence of the cause and to date few specifics about the treatment. Such ambiguity may lead friends and family to discount the condition and not appreciate how debilitating fibromyalgia can be. The studies described in this feature point us to two very important facts about fibromyalgia. First, something can be done. A combination of medications, behaviorally oriented psychotherapy, and exercise clearly help relieve the pain and increase the function of those suffering from the condition. Second, we are gaining knowledge about how to best tailor the combination of therapies to the individual needs of the patient. This knowledge assists clinicians in going beyond general and supportive recommendations to their patients. More specific therapies can lead to very real, not just marginal, improvement of symptoms and a much better quality of life. Those who suffer from fibromyalgia have every reason to be hopeful."

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Title Annotation:BONES & JOINTS
Publication:Duke Medicine Health News
Date:Sep 1, 2010
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