Fibromyalgia Customizing therapeutic management B. Van Houdenhove & P. Luyten B. Van Houdenhove & P. LuytenK.U.Leuven 1.

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

22

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…

44

““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.

3232

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…

3434

……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.

3535