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Fibromyalgia Customizing therapeutic management

Fibromyalgia Customizing therapeutic management. B. Van Houdenhove & P. Luyten K.U.Leuven. Outline. 1. Introduction 2. N on-pharmacological therapies in FM: efficacy , working mechanisms , outcome predictors 3. Toward customizing FM treatment

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Fibromyalgia Customizing therapeutic management

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  1. FibromyalgiaCustomizingtherapeutic management B. Van Houdenhove & P. Luyten K.U.Leuven

  2. Outline • 1. Introduction • 2.Non-pharmacologicaltherapies in FM: efficacy,workingmechanisms, outcomepredictors • 3. Towardcustomizing FM treatment • 4. Futuretreatmentresearch • 5. Conclusion

  3. 1.Introduction

  4. Fibromyalgia consists of multiplesymptomsamongwhich chronic, generalized pain, and pain hypersensitivity… • in the context of globalstress system disturbances • generalizedsensoryhypersensitivity • physical and mental effortintolerance • neuropsychological deficits • mood disorder • sleep cycledysregulation…

  5. “In addition to pain reduction, the factors that may contribute to perceptions ofimprovement 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)

  6. A further step… • Individualize therapeutic management of FM ? 6

  7. 2.Non-pharmacological therapies in FM: efficacy, working mechanisms, outcome predictors

  8. 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 meta-analysis of randomized controlled clinical trials. Arthritis Rheum 2009; 61: 216-24.

  9. Results… Psychologicalinterventions and exercisetherapy are effectivebut… relativesmallclinicalimprovements Effectstypicallynotmaintainedover time Efficacynotalwaystranslated in effectiveness Van Koulil S, et al. Ann Rheum Dis 2007; 66: 571-81.

  10. Efficacy = does the therapy work in ideal circumstances (RCT) ? • Effectiveness = does the therapy work in real life (natural setting, often involving complex cases) ? 10

  11. 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…) …and 11

  12. Results…(continued) • Great individual variationin treatment response… 12

  13. 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 !!!

  14. 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 Psychosom2005;74: 218-224.

  15. 3.Towardcustomizing FM treatment

  16. Reasons for unsatisfactory therapeutic results ? Therapeutic interventions in FM do not always fit with the patient’s individual characteristics, needs, and preferences

  17. 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 Pain2006; 22: 286-294.

  18. 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).

  19. Therapeutic strategies may be only effective when rooted in a plausible and acceptable therapeutic rationale

  20. So, what is ‘customized’ management ? use of various (psychological and biological / physiotherapeutic) interventions ‘à la tête du client’ …

  21. …giving attention to the doctor – patient relationship (and other non-specific factors) ….and based on a plausible and acceptable etio-pathogeneticworking hypothesis(‘illness theory’) of FM 21

  22. Biopsychosocialworking 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 dysfunctional pain inhibition perceptual-cognitive affective personality / behavioral social illness perception iatrogenic llness behaviour

  23. Psychotherapeutic and physiotherapeutic approaches could be customized by targeting specific, i.e. personally-relevant perpetuating factors…

  24. Physical factors Physical deconditioning Sleep disturbance Hyperventilation Opportunistic infections Perceptual-cognitive factors Prognostic uncertainty Somatic hypervigilance / preoccupation Rigid somatic attribution Catastrophising Low self-efficacy Affective factors Depression Anxiety disorders Kinesiophobia Personality factors Perfectionism / dependency Introversion Problematic affect regulation Alexithymia Behavioural factors Lack of adaptation / acceptance Periodical overactivity Social factors Lack of understanding Membership of patient group Secundary gain / operant conditioning Iatrogenic factors 24 Which perpetuating factors ?

  25. 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

  26. . 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

  28. 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

  29. 4.Futuretherapeuticresearch

  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. Tailoredcognitive-behavioraltherapyforfibromyalgia: Two case studies. PatientEducCouns2008; 71: 308-314. • Van Koulil S et al. Screening for pain-persistence and pain-avoidance patterns in fibromyalgia. Int J Behav Med 2008;15: 211-220. • Wilson HD et al. Toward the identification of symptompatterns in peoplewithfibromyalgia. ArthritisRheum2009; 61: 527-534. • Rutledge DN et al. Symptom clusters in fibromyalgia: potential utility in patientassessment and treatmentevaluation. NursRes 2009; 58: 359-367.

  32. 5.Conclusions

  33. Psychologicalàndbiologicalinterventions have a place in FM treatment but… shouldbecustomized 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

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