For the approximately five million Americans with fibromyalgia,1 there is an additional challenge on top of those typically faced by people with chronic disorders: lack of clarity about the very definition of the condition.
“There is a consensus among experts that fibromyalgia syndrome may not be a single disease, and that subgroups of fibromyalgia patients may be identifiable,” Juan V. Luciano, PhD, a psychologist and researcher at Parc Sanitari Sant Joan de Déu in Barcelona, Spain, told Neurology Advisor. “Developing meaningful treatments that patients benefit from over their lifetime remains a major challenge in providing clinical care” for the illness.
Since there is no known cure for fibromyalgia, the focus of treatment is on reducing symptoms and improving the patient’s level of functioning, typically with a combination of pharmacological and lifestyle interventions. The Federal Drug Administration has approved three medications for fibromyalgia treatment (duloxetine and milnacipran, which have antidepressant effects, and pregabalin for neuropathic pain),1 but researchers have found that their effectiveness is limited.2
The two non-pharmacological interventions that have been most studied are exercise, which helps to reduce pain, and cognitive behavioral therapy (CBT), which addresses some of the psychological components of the disorder.3 CBT increases patients’ belief in their ability to manage their condition, and it helps them change pessimistic thoughts and negative feelings regarding symptoms like pain, fatigue, and sleep problems. “Through CBT, fibromyalgic patients learn techniques that help them to manage their symptoms better and develop a different attitude towards pain — more acceptance and less catastrophising,” said Luciano.
Learning to Cope
Multiple studies have found that CBT is at least as effective as medication in reducing disability and symptoms like pain and negative mood in patients with fibromyalgia,4 and new research shows that there’s an additional benefit of using this approach in lieu of medication: it costs less.
In a randomized controlled trial reported in Arthritis Research & Therapy in October 2014, Spanish researchers assigned patients from 41 primary healthcare centers to one of three groups for the six-month study period: one group participated in nine group sessions of CBT; another group received a combination of pregabalin and duloxetine; and the third group received usual care from their primary care physician, which typically included a combination of medication and exercise recommendations.2 At the end of the study period, the CBT group scored higher on measures of quality of life, and this approach also demonstrated clear cost savings: while the average overall costs of medication and usual care were almost $4,000 and $3,400, respectively, the cost of CBT was approximately $2,000. The cost calculations considered the direct costs of doctor’s visits, medications, and medical testing, as well as the indirect cost of lost productivity. CBT offers yet another bonus: “Unlike pharmacological treatments, CBT does not cause side effects or complications,” said Luciano.
As promising as this treatment approach is, there is a shortage of trained CBT therapists, and even when access exists, their fees can be prohibitive for some patients. These are some of the main reasons “why CBT, which has the broadest database for efficacy in fibromyalgia, is grossly underutilized,” Robert Quinet, MD, a rheumatologist at Ochsner Medical Center in New Orleans, told Neurology Advisor.
Fortunately, there may be an option that negates those concerns. Quinet recently co-authored a study investigating the use of a freely available, 12-week online CBT program called the MoodGYM in patients with fibromyalgia.3 At both the six-week and 12-week marks, patients assigned to the internet-based program had lower scores on the Fibromyalgia Impact Questionnaire (which assesses current symptoms and level of functioning) than the control group, which received standard care. The online CBT participants also had lower tender point scores than controls at both of those time points.
“Online CBT is an option for technology literate patients — almost all — which is much more accessible and free, compared with the relative lack of trained cognitive behavioral therapists and their associated costs,” said Quinet.. “Nevertheless, training of more therapists would be of value as well, for those patients more responsive to personal instruction and those who can afford.”
Addressing Unique Needs
Ultimately, treatment should address the unique presentation of the patient. “It seems reasonable that some aspects of treatments should be universal — all should deal with the hyperalgesia, stiffness, and fatigue presented by most fibromyalgia patients,” said Luciano, while additional components, such as CBT and mindfulness, should be tailored depending on the presence of psychological symptoms.
In a recent pilot study supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), part of the National Institutes of Health, researchers found that combining CBT with a tailored exercise program led to improvements in teens with fibromyalgia.5 “The patients reported that they had more energy, that they were taking fewer naps and were more active in general,” study co-author Susmita Kashikar-Zuck, PhD, a professor of pediatrics and clinical anesthesiology at Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, told Neurology Advisor.
Managing pain in these and other patients may require a close collaboration between doctors, mental health clinicians, and physical therapists or exercise specialists. “Classifying patients into subgroups according to their clinical characteristics and tailoring pharmacological and non-pharmacological interventions might produce more favorable results than generic treatment programs,” said Luciano.
- National Institutes of Health: National Institute of Arthritis and Musculoskeletal and Skin Diseases. Fibromyalgia. Retrieved March 30, 2015 from http://www.niams.nih.gov/Health_Info/Fibromyalgia/default.asp
- Luciano JV, D’Amico F, Cerdà-Lafont M, et al. Cost-utility of cognitive behavioral therapy versus U.S. Food and Drug Administration recommended drugs and usual care in the treatment of patients with fibromyalgia: an economic evaluation alongside a 6-month randomized controlled trial. Arthritis Research & Therapy; 2014, 16:45
- Menga G, Ing S, Khan, O… Quinet R, et al. Fibromyalgia: Can Online Cognitive Behavioral Therapy Help? The Ochsner Journal; 2014; 14(3): 343–349.
- Bernardy K, Klose P, Busch AJ, et al. Cognitive behavioural therapies for fibromyalgia. Cochrane Database of Systematic Reviews; 2013; 9:CD009796.
- Kashikar-Zuck S, Tran ST, Barnett K, et al. A Qualitative Examination of a New Combined Cognitive Behavioral and Neuromuscular Training Intervention for Juvenile Fibromyalgia. The Clinical Journal of Pain; published online ahead of print.