Journal: J of Musculoskeletal Pain, Vol. 9(4) 2001, pp. 63-80
Authors: Karen Oliver, Terry A. Cronan and Heather R. Walen
Affiliations: Karen Oliver, BA [PhD Candidate], San Diego State University/University of California, Sun Diego, Joint Doctoral Program in Clinical Psychology, Project USE, San Diego, CA. Terry A. Cronan, PhD [Director/Professor], and Heather R. Walen, PhD [Project Director], San Diego State University, Project USE, San Diego, CA. Address correspondence to: Dr. Terry Cronan, Project USE, 6505 Alvarado Road, Suite 110, San Diego, CA 92120. The authors thank Drs. Silvia Bigatti, William Hillix, James Sallis, and two anonymous reviewers for comments on earlier drafts.
Preparation of this article was supported by NIH grant AR-44020.
Submitted: January 10, 2001.
Revision accepted: July 9, 2001.
Objectives: This paper reviews multidisciplinary treatment programs designed for people with fibromyalgia [FMS], identifies factors that may be associated with treatment efficacy, and makes recommendations for future FMS interventions.
Findings: Most efficacious interventions included physical activity and cognitive-behavioral therapy. Recommendations for future research studies
include: 1. the use of aerobic exercise and cognitive-behavioral therapy training in coping skills and relaxation; 2. individualized exercise training; 3. power analysis conducted a priori to determine appropriate sample size; 4. uniformity in outcome measurement and follow-up assessment; and 5. the use of randomized, controlled trials that can lead to stronger conclusions regarding treatment efficacy.
Conclusions: Multidisciplinary treatment programs for FMS patients are generally effective. Researchers should continue to develop multidisciplinary treatment interventions incorporating the above recommendations.
KEYWORDS. Fibromyalgia, review, multidisciplinary, interventions
INTRODUCTION Fibromyalgia syndrome [FMS] is a chronic condition of unknown origin characterized by fluctuating, but nearly continuous, pain. The major symptoms of FMS include musculoskeletal pain, headaches, sleep disturbance, fatigue, morning stiffness, and irritable bowel syndrome (1). No widely accepted biological marker has been found for FMS, although hypothesized plausible causal mechanisms include neurotransmitter imbalances and muscle fiber irregularities (2). A diagnosis of FMS is based on the American College of Rheumatology criteria of a history of widespread pain [pain on both sides of the body, above and below the waist, axially, and present for at least three months] in 11 or more of 18 tender-point sites located throughout the body (3). Fibromyalgia affects an estimated 3.4 percent of women and less than 1 percent of then, and in women is four times more common than rheumatoid arthritis (4).
The variety of symptoms associated with FMS, the tendency for symptom severity to fluctuate, and the lack of a clear biological cause make it difficult to treat FMS patients effectively. No universally effective treatment programs exist for FMS, although some forms of therapy work better than others (5-7 ). No medication has been consistently successful in treating FMS (6,8,9). Fibromyalgia typically does not respond well to traditional pain treatments used for other forms of rheumatic disease, such as anti-inflammatory drugs and steroids (10-12). Antidepressants such as serotonergic agents have produced some favorable results (13,14), although this claim has been disputed (15,16). Muscle relaxants and natural agents such as s-adenosyl-l-methionine also produce mixed results (17,18).
Behavioral interventions have produced greater improvement in patient reports of FMS symptoms and daily functioning than pharmacological interventions (19). However, behavioral interventions also yield inconsistent rates of success. These interventions have included physical activity, electroacupuneture, hypnotherapy, cognitive-behavioral therapy [CBT], and patient education. Of these interventions, those utilizing physical activity, CBT, or patient education have fared better than those that do not (20,21).
Because pharmacological and behavioral interventions have produced variable rates of success in treating FMS, researchers have examined the possibility that combining singular treatment modalities into multidimensional programs would yield better results than administering individual treatments one at a time (22-24). The findings of a recent meta-analysis examining 49 FMS treatment outcome studies support this notion, with the authors recommending interventions combining education, physical activity, and CBT for managing self-reported FMS symptoms and daily functioning, with appropriate pharmacological treatment as needed for individualized sleep and pain symptoms (19).
While various multidisciplinary FMS interventions have been reviewed elsewhere (e.g., 7,21,25), most multidisciplinary treatment studies have not been evaluated with the objective of guiding future treatment direction for patients with FMS. Therefore, the purpose of the present review is to examine multidisciplinary FMS interventions, to identify commonalties that may be associated with treatment efficacy, and to make recommendations for future treatment programs designed for patients with FMS. Unlike a meta-analysis that evaluates treatment efficacy based on effect sizes, the present review evaluates several aspects of the studies, taking into account not only treatment outcomes, but also related factors such as adherence. Because the studies reviewed will be evaluated post hoc, we do not seek to make definitive conclusions about a relationship between intervention components and treatment efficacy, nor to make direct comparisons across studies. Rather, the aim of this review is to provide suggestions for the direction of future FMS intervention research.
© 2001 by The Haworth Press, Inc. All rights reserved.