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Fibromyalgia Customizing therapeutic management B. Van Houdenhove & P. Luyten K.U.Leuven 1 Outline 1. Introduction 2. Non-pharmacological therapies in FM: efficacy, working mechanisms, outcome predictors 3. Toward customizing FM treatment 4. Future treatment research 5. Conclusion 2 1. Introduction 3 Fibromyalgia consists of multiple symptoms among which chronic, generalized pain, and pain hypersensitivity… in the context of global stress system disturbances – – – – – generalized sensory hypersensitivity physical and mental effort intolerance neuropsychological deficits mood disorder sleep cycle dysregulation… 4 “In addition to pain reduction, the factors that may contribute to perceptions of improvement among patients with fibromyalgia may include… …positive changes in fatigue, physical functioning, mood, and impact on daily living” Hudson JI et al. What makes patients with fibromyalgia feel better ? J Rheumatol (in press) 5 A further step… Individualize therapeutic management of FM ? 6 2. Non-pharmacological therapies in FM: efficacy, working mechanisms, outcome predictors 7 The efficacy of (mainly) – Cognitive-behavioral therapy (CBT) – Exercise therapy has been investigated by systematic reviews / meta-analyses of randomized controlled trials (RCT’s) van Koulil S, et al. Cognitive-behavioural therapies and exercise programmes for patients with fibromyalgia: state of the art and future directions. Ann Rheum Dis 2007; 66: 571-81. Häuser W, et al. Efficacy of multi-component treatment in fibromyalgia syndrome: A metaanalysis of randomized controlled clinical trials. Arthritis Rheum 2009; 61: 216-24. 8 Results… Psychological interventions and exercise therapy are effective but… relative small clinical improvements Effects typically not maintained over time Efficacy not always translated in effectiveness Van Koulil S, et al. Ann Rheum Dis 2007; 66: 571-81. 9 – Efficacy = does the therapy work in ideal circumstances (RCT) ? – Effectiveness = does the therapy work in real life (natural setting, often involving complex cases) ? 10 Results… (continued) Often no correlation between changes in pain and symptoms …and changes in psychological aspects (e.g. pain behaviors, functionality, self-efficacy, mood, coping…) 11 Results… (continued) Great individual variation in treatment response… 12 Working mechanisms CBT / exercise therapy may influence symptoms and disability via… – – – – redirecting reinforcement patterns correcting dysfunctional thoughts, beliefs, attributions… exposure to pain-related fear education, physical reconditioning …but these therapeutic ingredients are not relevant for every FM patient !!! 13 Predictors of positive therapeutic outcome highly distressed patients shorter history of complaints good compliance CFS: individual therapy better than group program ??? Van Koulil S, et al. Ann Rheum Dis 2007; 66: 571-581. Bazelmans et al. Psychother Psychosom 2005;74: 218-224. 14 3. Toward customizing FM treatment 15 Reasons for unsatisfactory therapeutic results ? Therapeutic interventions in FM do not always fit with the patient’s individual characteristics, needs, and preferences 16 Patient-therapist variables (‘non-specific’ therapeutic factors) are often not sufficiently taken into account Dopkin P.L. Predictors of adherence to treatment in women with fibromyalgia. Clin J Pain 2006; 22: 286-294. 17 To be noticed… FM patients reporting a history of childhood adversity may have particular psychosocial characteristics, e.g. personality disorders Physicians / therapists should be aware of such aspects that may have important implications for the therapeutic encounter Imbirowiecz & Egle. Eur J Pain 2003; 7: 113-119 . Van Houdenhove B et al. J Musculoskelet Pain (in press). 18 Therapeutic strategies may be only effective when rooted in a plausible and acceptable therapeutic rationale 19 So, what is ‘customized’ management ? use of various (psychological and biological / physiotherapeutic) interventions ‘à la tête du client’ … 20 …giving attention to the doctor – patient relationship (and other non-specific factors) ….and based on a plausible and acceptable etio-pathogenetic working hypothesis (‘illness theory’) of FM Biopsychosocial working hypothesis about the etio-pathogenesis of FM / CFS Predisposing factors familial-genetic early life stress depression personality / lifestyle stress system dysregulation Precipitating factors physical stressors psychosocial stressors hyper-function hypo-function ? Perpetuating factors immune activation / central sensitization physical perceptual-cognitive affective personality / behavioral social iatrogenic dysfunctional pain inhibition illness perception llness behaviour 22 Psychotherapeutic and physiotherapeutic approaches could be customized by targeting specific, i.e. personally-relevant perpetuating factors… 23 Which perpetuating factors ? Physical factors Physical deconditioning Sleep disturbance Hyperventilation Opportunistic infections Personality factors Perfectionism / dependency Introversion Problematic affect regulation Alexithymia Perceptual-cognitive factors Prognostic uncertainty Somatic hypervigilance / preoccupation Rigid somatic attribution Catastrophising Low self-efficacy Behavioural factors Lack of adaptation / acceptance Periodical overactivity Affective factors Depression Anxiety disorders Kinesiophobia Social factors Lack of understanding Membership of patient group Secundary gain / operant conditioning Iatrogenic factors 24 To be noticed… Many FM patients still suffer from ongoing life-stresses Some have co-morbid depression or a manifest post-traumatic stress disorder (e.g. following a car accident with whiplash trauma, …or worse) Van Houdenhove B, Egle UT, Luyten P: The role of life stress in fibromyalgia. Curr Rheumatol Rep 2005; 7; 365-370. In the long run… The therapeutic aim in FM should be broadened to: helping patients realistically adapt lifestyle and personal life goals which may minimize self-generated physical and mental stresses …in order to refind ‘a new psychological and neurobiological (?) equilibrium’ 27 Clinical implications: What works for whom ? myth of ‘one size fits all’ Who may be best helped by exercises? Who may rather benefit from behavioral or cognitive interventions? For whom would other approaches (family interventions, relaxation, assertiveness training, sleep restoration, counseling…) most useful ? Who may need a combination of strategies? Who may need specialized psychiatric therapy ? etc. 28 Organizational problems… Which clinician is best suited for coördinating the care for FM patients ? How to individualize treatment within multidisciplinary group settings ? Therapy on one-to-one basis ? What about the availability of psychotherapists / physiotherapists who are interested in, and have experience in these patients ? 29 4. Future therapeutic research 30 Is customized treatment more effective ? Naturalistic studies on ‘complex patients’ Role of non-specific therapy factors N=1 studies to elucidate processes of change Identification of therapeutic subgroups 31 Attempts to subgrouping… Van Koulil S et al. Tailored cognitive-behavioral therapy for fibromyalgia: Two case studies. Patient Educ Couns 2008; 71: 308-314. Van Koulil S et al. Screening for pain-persistence and painavoidance patterns in fibromyalgia. Int J Behav Med 2008;15: 211-220. Wilson HD et al. Toward the identification of symptom patterns in people with fibromyalgia. Arthritis Rheum 2009; 61: 527-534. Rutledge DN et al. Symptom clusters in fibromyalgia: potential utility in patient assessment and treatment evaluation. Nurs Res 2009; 58: 359-367. 32 5. Conclusions 33 Psychological ànd biological interventions have a place in FM treatment but… should be customized and individualized… 34 …targeting personally-relevant perpetuating factors in the context of a biopsychosocial working hypothesis …and taking non-specific therapeutic factors into account …in order to encourage the patient’s long-term self-care, lifestyle changes, and life goal re-orientation. 35