An ‘enigmatic’ disorder – this is what Perry Nicassio calls fibromyalgia. I hadn’t thought of it that way, because so many chronic pain problems seem to be equally ‘enigmatic’! It’s a common disorder, affects many more women than men, has a multiplicity of effects on people ranging from fatigue, poor sleep, widespread aching, other pain sensations such as stabbing or needle-like pains that can appear anywhere in the body, often with low mood and loss of function. There are few medications that seem to help, and many people never seek treatment for their pain. If people do look for treatment, they can be faced with skepticism from some health providers, despair from others, and offered a multiplicity of treatments that don’t seem to do an awful lot to change the situation.
Have I painted a bad enough picture? It’s only so the good news looks really good! And the good news is that in a recent meta-analysis of psychological therapies, there was a consistent finding that both short-term and longer term outcomes improved with this kind of input. OK, the effect sizes were small – but they were maintained, and the good thing about cognitive behavioural therapy (which was found to be the most effective ‘brand’ of therapy) is that once learned, no-one can take it away again, unlike medications!
The mainstay treatments for fibromyalgia include regular exercise - it seems that hydrotherapy is popular, but so is tai chi, pilates, walking, and really, anything that keeps the whole body moving. People with fibromyalgia also respond to learning more about their disorder - information is power! And to cognitive therapy - identifying unhelpful thinking and working with these to check out their helpfulness and accuracy, and then identifying new ways of viewing the situation. Other therapies commonly used, and studied in this meta-analysis, include biofeedback and relaxation training; sleep restriction and other forms of sleep management (eg sleep hygiene, cognitive therapy); activity management such as scheduling, pacing, planning, and graded increases in activity; behavioural strategies such as positive reinforcement for well behaviour and contingency management for illness behaviour; problem solving and communication strategies.
These don’t sound particularly different from the kind of therapy that most people with chronic pain receive within a cognitive behavioural approach. In other words, a full package of pain management strategies within a cognitive behavioural approach seems to have the best short-term and long-term effect on things like sleep, pain intensity, mood, activity level – and even catastrophising!
There are always questions raised in studies like this.
Why were only 23 studies from the original 1530 identified? Methodological limitations hampered inclusion of many of these studies – too few details provided in the research paper, no control groups, limited descriptions of how people were selected for the treatment and what happened to people who dropped out, or other treatments such as pharmacology were continued so that good conclusions couldn’t be drawn from the results.
But other questions are also raised. What are the mechanisms that psychological therapies are working on? How do they work? Why is that something that influences pain intensity can also influence sleep quality and mood problems? Does this mean these problems are linked somehow? Could this mean that if we addressed just sleep, for example, these other problems might resolve themselves?
Are all people with widespread pain actually experiencing fibromyalgia? If there is a spectrum of symptoms, ranging from full-blown low mood, poor sleep, deactivation and tender points along with the aching, and all points in between, does this mean that different parts of the central nervous system are affected? Is it all one disorder? Would being able to identify subgroups help with treatments?
These are the same sort of arguments that plague low back pain management - and given the somewhat more straightforward conceptual models of back pain, I would hope things like sub-groups and specific treatments might be slightly clearer – but this is not the case! So I guess that fibromyalgia may also present a more vexing problem, and the research questions will continue to flow.
I can’t summarise the state of play regarding treatment for fibromyalgia any better than the authors of this meta-analysis:
Clinicians treating fibromyalgia patients with psychological methods should keep in mind that they can successfully work with their patients on several goals, such as reducing pain, sleep problems and catastrophizing and elevating mood and daily functioning. However, both clinicians and patients should also be aware that the effects will likely be rather small and require a high number of sessions to occur. Fibromyalgia is a heterogeneous disease and there is evidence that some drugs or exercise is moderately effective for treating the disorder. Multicomponent therapies have been shown to be effective, although only in the short-term. Thus, based on the results of this study, we suggest treating fibromyalgia patients with a combination of methods that include psychological interventions as a major component.
What does this mean for clinicians who are not psychologists? Well, I can’t find evidence to suggest that clinicians of other persuasions can’t be effective at delivering a cognitive behavioural approach to pain management.
The basics of this type of therapy are common to occupational therapists, physiotherapists, nurses, social workers and others - what might be needed now is a concerted effort by ‘non-psychologists’ to establish ways of integrating psychological strategies within the treatment paradigms of these professions.
For me, I continue to focus on goals that the person wants - usually things like sleep management, ability to return to work, being able to manage the household activities, return to leisure activities – the sort of things I discussed in yesterday’s post about what patients want. Good pain management is really about using the most effective tools to help people achieve these goals, and to me, the goals represent what my core profession values the most – occupation.
Nicassio, P. (2010). Psychological approaches are effective for fibromyalgia: Remaining issues and challenges Pain, 151 (2), 245-246 DOI: 10.1016/j.pain.2010.08.011
Glombiewski, J., Sawyer, A., Gutermann, J., Koenig, K., Rief, W., & Hofmann, S. (2010). Psychological treatments for fibromyalgia: A meta-analysis Pain, 151 (2), 280-295 DOI: 10.1016/j.pain.2010.06.011