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FibromyalgiaFibromyalgia
Customizing therapeutic Customizing therapeutic managementmanagement
B. Van Houdenhove & P. LuytenB. Van Houdenhove & P. Luyten
K.U.LeuvenK.U.Leuven
11
OutlineOutline1. 1. IntroductionIntroduction
2.2. N Non-pharmacological therapies in FM: on-pharmacological therapies in FM: efficacy,efficacy, working mechanisms, outcome predictors working mechanisms, outcome predictors
3. Toward 3. Toward customizing customizing FM treatment FM treatment
4. Future treatment 4. Future treatment researchresearch
5. 5. Conclusion Conclusion
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1.1. IntroductionIntroduction
33
FibromyalgiaFibromyalgia consists of consists of multiplemultiple symptoms symptoms among which among which
chronic, generalized pain, chronic, generalized pain, andand pain hypersensitivity… pain hypersensitivity…
in the context of global in the context of global stress system disturbancesstress system disturbances
– generalized sensory hypersensitivity generalized sensory hypersensitivity – physical and mental effort intolerancephysical and mental effort intolerance– neuropsychological deficitsneuropsychological deficits– mood disordermood disorder– sleep cycle dysregulation… sleep cycle dysregulation…
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““In addition to In addition to pain reductionpain reduction, the factors that , the factors that may contribute to may contribute to perceptions ofperceptions of improvementimprovement among patients with fibromyalgia among patients with fibromyalgia may include… may include…
… …positive changes in positive changes in fatiguefatigue, , physical physical functioningfunctioning, , moodmood, and , and impact on daily livingimpact on daily living””
Hudson JI et al. What makes patients with fibromyalgia feel better ? Hudson JI et al. What makes patients with fibromyalgia feel better ? J RheumatolJ Rheumatol (in press) (in press)
55
A further step…
Individualize
therapeutic management
of FM ? 6
2.2.
Non-pharmacological Non-pharmacological
therapies in FM: therapies in FM:
efficacyefficacy, ,
working mechanismsworking mechanisms, ,
outcome predictorsoutcome predictors77
The efficacy of (mainly) The efficacy of (mainly)
– Cognitive-behavioral therapy (CBT)Cognitive-behavioral therapy (CBT)– Exercise therapyExercise therapy
has been investigated by has been investigated by systematic reviews / meta-systematic reviews / meta-analyses analyses ofof randomized controlled trials (RCT’s) 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 meta-analysis of
randomized controlled clinical trials. Arthritis Rheum 2009; 61: 216-24.
88
Results…Results…
Psychological interventions Psychological interventions and exercise therapy are and exercise therapy are effectiveeffective but… but… relative relative small small clinical improvementsclinical improvements
Effects typically Effects typically not maintainednot maintained over over timetime
EfficacyEfficacy not always translated in not always translated in effectivenesseffectiveness
Van Koulil S, et al. Ann Rheum Dis 2007; 66: 571-81.
99
– Efficacy Efficacy = does the therapy work in ideal = does the therapy work in ideal circumstances (RCT) ?circumstances (RCT) ?
– EffectivenessEffectiveness = does the therapy work = does the therapy work in real life (natural setting, often involving in real life (natural setting, often involving complex cases) ?complex cases) ?
1010
ResultsResults…… (continued)(continued)
OftenOften no correlation no correlation between between changes changes inin pain pain
andand symptoms symptoms
…and changes in psychological aspects (e.g. pain behaviors, functionality, self-efficacy, mood, coping…)
…and1111
Results…Results… (continued)(continued)
Great Great individual individual
variationvariation in treatment in treatment response…response…
1212
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 !!!
1313
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. 1414
3.3.
Toward Toward customizing customizing
FM FM treatmenttreatment
1515
Reasons for
unsatisfactory
therapeutic results ?
Therapeutic interventions in FM Therapeutic interventions in FM do do notnot always fit with always fit with the patient’s individual characteristics, the patient’s individual characteristics, needs, and preferences needs, and preferences
1616
Patient-therapist variables Patient-therapist variables
(‘non-specific’ therapeutic factors) (‘non-specific’ therapeutic factors)
are often are often notnot sufficiently sufficiently
taken into accounttaken into account
1717
Dopkin P.L. Predictors of adherence to treatment in women with fibromyalgia.Clin J Pain 2006; 22: 286-294.
To be noticed…
FM patients reporting a history of FM patients reporting a history of childhood childhood
adversityadversity may have particular psychosocial may have particular psychosocial
characteristics, e.g. characteristics, e.g. personality disorderspersonality disorders
Physicians / therapists should be aware of such Physicians / therapists should be aware of such
aspects that may have aspects that may have important implicationsimportant implications for the for the
therapeutic encountertherapeutic encounter
Imbirowiecz & Egle. Eur J Pain 2003; 7: 113-119 . Van Houdenhove B et al. J Musculoskelet Pain (in press).
1818
Therapeutic strategies may be Therapeutic strategies may be
onlyonly effective effective
when rooted in a plausible and when rooted in a plausible and
acceptable therapeutic rationaleacceptable therapeutic rationale
1919
So, what is ‘customized’ So, what is ‘customized’ management ?management ?
use of various (psychological and use of various (psychological and biological / physiotherapeutic) biological / physiotherapeutic) interventionsinterventions
‘‘à la tête à la tête du client’ …du client’ …
2020
…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 21
Biopsychosocial working hypothesis Biopsychosocial working hypothesis about the etio-pathogenesis of FM / CFSabout the etio-pathogenesis of FM / CFS
Predisposing factorsPredisposing factors
familial-geneticfamilial-genetic
early life stressearly life stress
depressiondepression
personality / lifestylepersonality / lifestyle
stress system dysregulation stress system dysregulation
Precipitating factorsPrecipitating factors
physical stressorsphysical stressors
psychosocial stressorspsychosocial stressors
hyperhyper--function function hypohypo--function function ??
Perpetuating factors Perpetuating factors immune activation / central sensitizationimmune activation / central sensitization
physicalphysical dysfunctional pain inhibitiondysfunctional pain inhibition perceptual-cognitive perceptual-cognitive
affective affective
personality / behavioralpersonality / behavioral
social illness perceptionsocial illness perception
iatrogenic llness behaviouriatrogenic llness behaviour
2222
Psychotherapeutic Psychotherapeutic andand physiotherapeutic approaches physiotherapeutic approaches could could be customizedbe customized
by targeting by targeting specificspecific, ,
i.e. i.e. personally-relevantpersonally-relevant
perpetuating factors…perpetuating factors…
2323
Which perpetuating factors ?Physical factors
Physical deconditioningSleep disturbanceHyperventilationOpportunistic infections
Perceptual-cognitive factorsPrognostic uncertaintySomatic hypervigilance / preoccupationRigid somatic attributionCatastrophisingLow self-efficacy
Affective factors
DepressionAnxiety disordersKinesiophobia
Personality factorsPerfectionism / dependencyIntroversionProblematic affect regulationAlexithymia
Behavioural factorsLack of adaptation / acceptancePeriodical overactivity
Social factorsLack of understandingMembership of patient groupSecundary 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.
25
. .
In the long run…In the long run…
The therapeutic The therapeutic aimaim
in FM should be in FM should be broadenedbroadened to: to:
helping patients realistically helping patients realistically
adapt lifestyle and personal life goalsadapt lifestyle and personal life goals
which may which may minimizeminimize self-generated self-generated
physical and mental physical and mental stressesstresses
… …in order to refind in order to refind ‘a new psychological ‘a new psychological and neurobiological (?) equilibrium’and neurobiological (?) equilibrium’
2727
Clinical implications: What works for whom ?
myth of
‘one size fits all’
Who may be best helped by Who may be best helped by exercisesexercises??
Who may rather benefit from Who may rather benefit from behavioralbehavioral or or cognitive interventionscognitive interventions??
For whom would other approaches (For whom would other approaches (family interventions, relaxation, family interventions, relaxation,
assertiveness training, sleep restoration, counseling…) assertiveness training, sleep restoration, counseling…) most useful ? most useful ?
Who may need a Who may need a combination combination of strategiesof strategies? ?
Who may need Who may need specialized psychiatric therapyspecialized psychiatric therapy ? etc. ? etc. 28 28
Which clinician Which clinician is best suited for coördinating the care is best suited for coördinating the care for FM patients ? for FM patients ?
How to How to individualizeindividualize treatment within treatment within multidisciplinary multidisciplinary group settingsgroup settings ? ?
Therapy on Therapy on one-to-oneone-to-one basis ? basis ?
What about the What about the availabilityavailability of psychotherapists / of psychotherapists / physiotherapists who are interested in, and have experience physiotherapists who are interested in, and have experience in these patients ? in these patients ?
2929
OrganiOrganizzational problems…ational problems…
4.4. Future therapeutic Future therapeutic
research research
3030
IsIs customized customized treatmenttreatment more effective ? more effective ?
NaturalisticNaturalistic studies on ‘complex patients’ studies on ‘complex patients’
Role ofRole of non-specific non-specific therapy factors therapy factors
N=1 studiesN=1 studies to elucidate processes of change to elucidate processes of change
Identification of therapeutic Identification of therapeutic subgroupssubgroups
3131
Attempts to subgrouping…Attempts to subgrouping…
Van Koulil S et al. Tailored cognitive-behavioral therapy for Van Koulil S et al. Tailored cognitive-behavioral therapy for fibromyalgia: Two case studies. fibromyalgia: Two case studies. Patient Educ Couns Patient Educ Couns 2008; 71: 2008; 71: 308-314.308-314.
Van Koulil S et al. Screening for pain-persistence and pain-avoidance Van Koulil S et al. Screening for pain-persistence and pain-avoidance patterns in fibromyalgia. patterns in fibromyalgia. Int J Behav Med Int J Behav Med 2008;15: 211-220. 2008;15: 211-220.
Wilson HD et al. Toward the identification of symptom patterns in Wilson HD et al. Toward the identification of symptom patterns in people with fibromyalgia. people with fibromyalgia. Arthritis Rheum Arthritis Rheum 2009; 61: 527-534.2009; 61: 527-534.
Rutledge DN et al. Symptom clusters in fibromyalgia: potential utility Rutledge DN et al. Symptom clusters in fibromyalgia: potential utility in patient assessment and treatment evaluation. in patient assessment and treatment evaluation. Nurs ResNurs Res 2009; 58: 2009; 58: 359-367.359-367.
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5.5. ConclusionsConclusions
3333
Psychological ànd biological Psychological ànd biological interventions have a place interventions have a place in FM treatment in FM treatment
but… but…
should be customized should be customized and individualized… and individualized…
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……targeting personally-relevant perpetuating targeting personally-relevant perpetuating factorsfactors
in the context of a biopsychosocial working in the context of a biopsychosocial working hypothesishypothesis
… …and taking non-specific therapeutic factors and taking non-specific therapeutic factors into account into account
……in order to encourage the patient’s long-term in order to encourage the patient’s long-term self-care, lifestyle changes, and life goal self-care, lifestyle changes, and life goal re-orientation.re-orientation.
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