Routine physical exercise is an important factor in managing widespread musculoskeletal pain in conditions such as fibromyalgia (FM), but patients may fear that such exertion will worsen pain. Now, results of a pilot study suggest that a combination of cognitive behavioral therapy (CBT) that emphasizes pain coping strategies and a specially tailored exercise program reduces this fear for teenagers with juvenile fibromyalgia (JFM). The program also improved physical function and may help these patients become more physically active.
Susan T. Tran, PhD, from the Department of Psychology, DePaul University, Chicago, Illinois, and colleagues reported preliminary outcomes for 22 patients in an article publsihed June 22 in Arthritis Care & Research.
“Results of this pilot study indicated that adolescents with JFM reported significant improvements in physical function and reduced fear of movement following the intervention,” the authors write. “Improvement in physical function was achieved in a shorter time frame than a prior trial of CBT without an exercise component.” They plan further to determine whether these outcomes result in changes in exercise participation and whether combined CBT/exercise is better than existing approaches.
The 8-week, 16-session intervention developed by Dr Tran and colleagues, dubbed the Fibromyalgia Integrative Training for Teens (FIT Teens) program, included twice-weekly 90-minute small-group treatment sessions. Sessions were led jointly by a psychology postdoctoral fellow or pediatric pain psychologist and an exercise physiologist or physical therapist. Parents were included in 6 of the 8 weeks. There was no control group.
Each session included approximately 45 minutes of CBT training in behavioral pain management techniques and 45 minutes of neuromuscular exercises to improve strength, fitness, and body mechanics. CBT included education about the gate-control theory of pain, as well as coping skills such as distraction, relaxation techniques, activity pacing, problem solving, and changing negative and catastrophic thoughts about pain. These skills were then practiced with coaching from the psychology fellow or psychologist while the participants went through the exercise training.
Exercise training used only bodyweight resistance exercises to permit easy home use of the program. Subjects progressed through four increasingly strenuous levels of resistance training during the 8 weeks.
“Education normalizing temporary muscle soreness when beginning a new exercise regimen and differentiating muscle soreness from a JFM pain flare was also discussed, as well as the applicability of each of the exercises for improved performance of activities of daily living—e.g., walking, lifting, and climbing stairs,” the authors write.
Progress was monitored via daily diaries that included ratings of daily pain intensity, sleep, fatigue, practice of coping skills, and physical exercise. Patients also completed self-report measures of pain, functional disability, depressive symptoms, and fear of movement. The following tools were used for symptom assessment: a 10-point visual analogue scale for pain intensity, the functional Disability Inventory, the Children’s Depression Inventory, the Tampa Scale for Kinesophobia, the Pain Catastrophizing Scale for Children, and the Pain Stages of Change Questionnaire to assess readiness to self-manage pain.
The researchers enrolled 22 female patients (aged 12 – 18 years) from two urban children’s hospitals. Patients were treated in groups of two to four. Eligibility criteria included JFM diagnosis by a pediatric rheumatologist or pain physician, using Yunus and Masi criteria (widespread pain, at least five tender points, and associated symptoms such as fatigue or sleep disturbance). Eligibility also required an average visual analogue scale pain intensity of more than 4 and a Functional Disability Score of more than 7 (at least mild disability). Exclusion criteria included severe depression, comorbid rheumatic disease, other untreated major psychiatric diagnosis, or developmental delay.
The researchers report that comparison of pre- vs postintervention assessments showed significant decreases in functional disability, depression fear of movement, and pain catastrophizing, as well as significant improvements in “readiness to change” measures.
There was no significant effect on pain intensity, although pain scores decreased. The researchers suggest that the gradual increases in physical activity during this 8-week program might not have been sufficient to attain the kind of pain reduction seen after longer aerobic exercise studies.
“This multi-site investigation provides promising initial evidence for the feasibility and efficacy of a novel intervention that combines CBT with neuromuscular training to reduce disability and fear of movement, while improving psychological coping and readiness to engage in self-management for pain. As we have reported in a previously published qualitative study, once enrolled, patients find FIT Teens highly engaging, report no adverse effects other than temporary muscle soreness, and greatly enjoy the group-format of this program,” the authors write.
They also note that physical function improvements were achieved faster than in a prior trial of traditional pain-focused CBT without exercise.
Study limitations included lack of a control group, which precludes ruling out a placebo effect, and lack of objective measures such as physical activity and biomechanical outcomes.